Shaw’s Textbook of Operative Gynaecology. 7e [7 ed.]

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Sha w’s Te xtb o o k o f O pe ra tive G yna e c o lo g y

Sha w’s Te xtb o o k o f O pe ra tive G yna e c o lo g y Seventh Edition Editors: Marcus E. Setchell CVO MB B.Chir (Cantab) FRCS (Eng & Edin) FRCOG Surgeon-Gynaecologist to HM he Queen, Consultant Gynaecologist, King Edward VII Hospital, and London Clinic, Consultant Obstetrician, Portland Hospital & Lindo Wing, St. Mary’s Hospital, London Honorary Consultant Obstetrician and Gynaecologist, St. Bartholomew’s, Homerton and Whittington Hospitals, London Formerly Examiner, Royal College of Obstetricians and Gynaecologists, Universities of Cambridge, London, and University of Colombo, Sri Lanka Royal Society of Medicine: President, Section of Obstetrics and Gynaecology, 1994 Clinical Specialist Adviser (Gynaecology), National Patient Safety Agency, 2003–6

Professor John H. Shepherd MBBS (Lond) FRCSEng FRCOG Consultant Surgeon & Gynaecological Oncologist, he Royal Marsden Hospital, London Honorary Consultant Gynaecologist, King Edward VII Hospital, London Honorary Consultant Gynaecological Surgeon, St. Bartholomew’s and he Royal London Hospitals, London Emeritus Professor of Surgical Gynaecology, St. Bartholomew’s and he Royal London School of Medicine, Queen Mary Westield, University of London Gold Medal MRCOG exam. 1978, Fulbright Hays Scholarship 1979, American Cancer Society Fellowship 1979–1981 Victor Bonney Award 1982, Victor Bonney Lecturer RCOG 1998, Hunterian Professor RCS, 2006–2007 William Meredith Fletcher Shaw Lecturer, RCOG 2012 Royal Society of Medicine, Section of Obstetrics & Gynaecology, President 2006, Society of Pelvic Surgeons, President 2008, International Federation of Obstetrics and Gynaecology (FIGO), Member Committee Gynaecological Oncology 1985–1998 Editorial Committee for Annual Report of Gynaecological Cancer 1993–2001 UK Co-ordinating Committee for Cancer Research, Chairman of Gynaecology Sub-committee 1994–1997 British & Irish Association of Robotic Gynaecological Surgeons, President 2010–2013 Visiting Professorships: America, Australia, Singapore, Hong Kong, China, Middle East, India and Europe Consulting Editor: Christopher N. Hudson MB M.Chir (Cantab) FRCS (Eng & Glas) FRCOG FRANZCOG Consulting Obstetric and Gynaecological Surgeon, St. Bartholomew’s and Homerton Hospitals Emeritus Professor of Obstetrics and Gynaecology, St. Bartholomew’s and the Royal London School of Medicine Former Professor of Obstetrics and Gynaecology, University of Sydney and Director of Obstetrics and Gynaecology, Westmead Hospsital; sometime Hon. Consultant University of Ibadan, Nigeria Hunterian Professor 1969, Victor Bonney Lecturer 1980, Royal College of Surgeons of England William Meredith Fletcher Shaw Lecturer, Royal College of Obstetricians and Gynaecologists, 1999 Paul Hendrickse Lecturer, University of Ibadan 1982

Sub-Editor: Tom E. Setchell BMBS (Notts) MRCOG Consultant Minimal Access Gynaecological Surgeon and Obstetrician St. Mary’s Hospital, Imperial NHS Trust London, UK

ELSEVIER A division of Reed Elsevier India Private Limited

Shaw’s Textbook of Operative Gynaecology, 7/e Setchell, Shepherd & Hudson

ELSEVIER A division of Reed Elsevier India Private Limited

Mosby, Saunders, Churchill Livingstone, Butterworth-Heinemann and Hanley & Belfus are the Health Science imprints of Elsevier.

© 2013 ME Setchell, JH Shepherd & CN Hudson First Edition 1954 Second Edition 1960 Third Edition 1968 Fourth Edition 1977 Fifth Edition 1983 Sixth Edition 2001 Seventh Edition 2013

All rights are reserved. No part of this publication may be reproduced, stored in a retrieval system, or transmitted in any form or by any means, electronic, mechanical, photocopying, recording, or otherwise without the prior permission of the publisher.

ISBN: 978-81-312-1160-1

Medical knowledge is constantly changing. As new information becomes available, changes in treatment, procedures, equipment and the use of drugs become necessary. The author, editors, contributors and the publisher have, as far as it is possible, taken care to ensure that the information given in this text is accurate and up-to-date. However, readers are strongly advised to confirm that the information, especially with regard to drug dose/usage, complies with current legislation and standards of practice. Please consult full prescribing information before issuing prescriptions for any product mentioned in this publication.

Published by Elsevier, a division of Reed Elsevier India Private Limited. Registered Office: 305, Rohit House, 3 Tolstoy Marg, New Delhi-110 001. Corporate Office: 14th Floor, Building No. 10B, DLF Cyber City, Phase II, Gurgaon–122 002, Haryana, India.

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Pre fa c e

The preface to the sixth edition of Shaw’s Textbook of Operative Gynaecology opened by raising questions about the long-term viability of operative surgery books in a world where advances in information technology were dramatically changing the way in which information is disseminated, with profound effects on methods of learning and teaching. Despite the continuing pace of progress in the development and application of digital technology, the demand still remains for a state-of-the-art book, which can live on a bookshelf or in the operating theatre. It is therefore, no surprise, that the publishers have sought a new edition, when the book is fast approaching the age of expected retirement, it being almost 60 years since the first edition* was published. The globalisation of publishing had seen the rights of the work transferred to B. I. Churchill Livingstone in New Delhi in 1993. That company has now been absorbed into the very large international publishing company, Elsevier. It is entirely appropriate for the publication of this book to continue to be in Delhi, as the technology and skills of publication and printing have risen to such high standards in India. Demography, economics and historical medical associations make it sensible to produce a hard copy book close to where the market is greatest. Nevertheless, it is predicted that the book will continue to be in demand by postgraduate trainees and consultants in the UK, Europe, Africa and the Middle Eastern countries, as well as Australia and New Zealand and many other parts of the world. We are fortunate that Elsevier’s worldwide organisation means that the book can be distributed literally all over the world. The last edition’s Preface also acknowledged the increasing sub-specialisation within medicine generally, and notably in gynaecological surgery. The benefits to the patient of being cared for by sub-specialists and their teams have become increasingly apparent, and most sizeable departments throughout the world have now embraced this principle. The sub-specialties of Gynaecological Oncology, Fertility and Reproductive Medicine, Gynaecological Urology and Pelvic Floor are now well developed, whilst minimal access surgery, endometriosis and fibroid treatment, fistula surgery and many other specialist areas of gynaecology are becoming recognised as disciplines where patient care improves if there is a concentration of the workload to a smaller number of individual surgeons. This has led to a major change in the authorship structure of the book. We have commissioned a large number of experts in the sub-specialties to review and rewrite much of the material. In previous editions, the majority of the contributors were members of the staff of St. Bartholomew’s Hospital, but writers have now been recruited from many other centres of excellence. We welcome them warmly and thank them for their contribution of time, skill and energy. Inevitably this has led to some loss of consistency in style, but the Editors feel that any disadvantage of this is far outweighed by the intense experience that the sub-specialist authors bring to their subjects. No longer can a surgeon simply quote their preferences for a particular technique based on individual experience, but must write from a position of knowledge of objective evidence-based outcome measures. All authors have been encouraged to give attention to the prevention and management of complications within their specialist area. These new chapters are complemented by many new colour digital photographs, which with modern technology can be inserted at any chosen point in the text. There are also major changes in the editorship of this seventh edition. Professor Christopher N. Hudson who has been an Editor of the last three editions becomes Consulting Editor. His contribution to this book has been considerable. He trained under, and worked with, Mr. John Howkins (qv below) and was appointed Co-editor in 1977. His long association and working experience with departments in Africa and other tropical countries have brought special expertise to the surgical management of fistulae and obstetric trauma. As one of the first gynaecological cancer specialists, he has also brought particular expertise to this area. We are grateful for his continuing guidance and for retaining authorship of the chapter on Surgical Anatomy. The senior Editor (MES) trained at a time when gynaecological trainees at the end of their apprenticeship were expected to be able to carry out the whole panoply of gynaecological operations, including surgery for cancer, pelvic floor repairs, infertility, as well as benign hysterectomy, myomectomy and endometriosis, and the new procedures of diagnostic laparoscopy and laparoscopic sterilisation. In addition, holding the Fellowship of one or more of the surgical colleges, and/or the acquisition of a postgraduate MD or PhD by thesis, were almost mandatory before becoming a Consultant. Although consultants were expected to be generalists by and large, many took on a “special interest” according to the needs of their department. In this writer’s first Consultant post, the inheritance of an established tertiary practice for adolescent and paediatric gynaecology on joining the staff of St. Bartholomew’s Hospital called for some rapid learning, and subsequent needs of the Department led to the unlikely combination of heading up the pregnancy termination service and Assisted Conception Unit simultaneously. Not surprisingly, the need for sub-specialist appointments was soon recognised and St. Bartholomew’s Hospital was fortunate in being able to appoint a sub-specialist in gynaecological oncology who had undergone a full sub-specialist training programme in the USA in the shape of Mr. (now Professor) John Shepherd. His appointment to co-editorship is therefore most welcome, and his revision and updating of the gynaecological cancer chapters has been particularly valued. A matter for discussion between the publishers and editors in future editions will be the extent to which the book should become an online publication, perhaps with associated digital recordings of operative procedures.

Preface We hope the book will continue to be a training manual for generalist trainees and serve as a learning aid during their operative training experience, as well providing in-depth knowledge of some operations that they may never expect to perform unless they proceed to sub-specialist training. For those who do, knowledge and know-how of the more specialised operations described will be invaluable. In addition, those generalists who may take a special interest in aspects of benign gynaecology will find detailed descriptions of laparoscopic surgery helpful.

Acknowledgments Most of the new artwork has been provided by Mrs. Joanna Cameron, to whom we are most grateful. We also thank our nongynaecological colleagues who have provided chapters on anaesthesia, oncology, imaging and radiotherapy, as well as medico-legal aspects. Much of the typing and incorporation of editorial amendments has been carried out by Katherine Fletcher, Medical Secretary. The editors also acknowledge the help of their personal secretaries, and wives and families whose computer skills have supplemented their basic skills. The authors and editors also acknowledge that many hours of “family time” have been sacrificed to make completion of this task possible. We are especially grateful to Mr. Tom Setchell who has been co-opted as Sub-Editor. Finally, we are grateful to the whole team of our publishers, Elsevier, Delhi for their tolerant patience, help and encouragement to see this project to conclusion. 2012

MES JHS

*Historical Note Wilfred Shaw MD FRCS FRCOG, the first author and Editor of this textbook was born in 1897. He was educated at Cambridge University and St. Bartholomew’s Hospital, where his academic brilliance was recognised by the award of many prizes. His medical training was interrupted by the First World War where he served in a destroyer as ‘Surgeon Probationer’, delaying his qualification as a doctor until 1921. His MD thesis from Cambridge on the oestrogen-producing cells of the ovary resulted in the Prize for the best thesis, and he went on to gain many other prestigious awards. Unusually for the times, he undertook postgraduate training in Vienna, Berlin, Gratz and Dublin. He was a foundation member of the Royal College of Obstetricians and Gynaecologists, and was appointed to the staff of St. Bartholomew’s Hospital in 1930. He was a brilliant and innovative surgeon, devising many new operations as well as writing papers on ovarian physiology and histology. His hobbies included Astrophysics, English history and poetry, and horticulture, becoming an expert in fruit tree grafting. He developed a serious illness in 1951, which he knew would be fatal. In forced retirement, he proceeded to write his Textbook of Operative Gynaecology, which was published shortly after his death in 1953 at the age of 55. Of great significance is the death of former Editor, Mr. John Howkins in 2003. Born in 1907, he qualified from the Middlesex Hospital in 1932. His training was interrupted by the Second World War where he served in the Royal Air Force. After the war, he was appointed Consultant Gynaecologist to St. Bartholomew’s Hospital, joining Mr. Wilfred Shaw. On retirement in 1970, he became a sheep farmer in Wales, a second career that he enjoyed for 30 years. His contribution and interest in this book had continued for almost 50 years, and this long experience will be greatly missed. Some blocks of his text remain intact as their clarity and eloquence cannot be surpassed. We have also retained a substantial number of the illustrations from previous editions because of the clarity of many of these beautifully executed drawings that provide examples of the historical development of medical art and surgical teaching.

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C o ntrib uto rs

Ada m Ba le n MD DSc FRCOG

Professor of Reproductive Medicine and Surgery, Leeds Teaching Hospitals Leeds Centre for Reproductive Medicine, Leeds, UK

Ala n Fa rthing MD FRCOG

Consultant Gynaecological Surgeon Imperial College NHS Trust London, UK

Anju Sa hde v MBBS MRCP FRCR

Consultant Radiologist & Senior Lecturer St. Bartholomew’s Hospital Barts Health NHS Trust, London, UK

Axe l Wa lthe r MA MRCP PhD

Consultant Medical Oncologist Head of Research, Bristol Haematology and Oncology Centre Honorary Senior Lecturer, University of Bristol University Hospitals Bristol, UK

Be rtie Le ig h Hon FRCPCH FRCOG ad eundem

Senior Partner Hempsons, London, UK

Bha vna G a m i BSc (Hons) MSc MBBS

Academic FY2 in Surgery Department of Biosurgery & Surgical Technology, Faculty of Medicine Imperial College London, UK

C a rl C ho w MBBS BSc MRCOG

Consultant Obstetrician & Gynaecologist Kingston Hospital NHS Trust London, UK

C a ro line E. Eve rde n MBBS MRCOG

Obstetrics & Gynaecology Specialist Trainee

C hristia n Ba rnic k MBBS FRCOG

Consultant Obstetrician & Gynaecologist Homerton University Hospital, London, UK

C hristine Sc he m b ri De g ua ra MD

Clinical Research Fellow Reproductive Medicine Department St. Bartholomew’s Hospital, London, UK

C hristo phe r N. Hudso n MB MChir (Cantab) FRCS (Eng & Glas) FRCOG FRANZCOG

Consulting Obstetric & Gynaecological Surgeon St. Bartholomew’s & Homerton Hospitals Emeritus Professor, Obstetrics & Gynaecology St. Bartholomew’s and the Royal London School of Medicine and Dentistry

C la ire Me llo n MBChB MRCOG

Consultant Obstetrician & Gynaecologist he Whittington Hospital NHS Trust London, UK

Contributors

C live Spe nc e - Jo ne s FRCS FRCOG

Consultant Gynaecologist & Obstetrician he Whittington Hospital NHS Trust London, UK

C o lin Da vis MBBS MD FRCOG

Consultant Obstetrician & Gynaecologist St. Bartholomew’s Hospital, London, UK

Dudle y Ro b inso n MBBS MD FRCOG

Consultant Urogynaecologist Honorary Senior Lecturer Kings College Hospital London, UK

Em m a Kirk MD MRCOG

Senior Registrar in Obstetrics & Gynaecology Whittington Hospital NHS Trust London, UK

viii

Erik Ma ye r PhD FRCS (Urol)

Clinical Lecturer in Surgery & Senior Registrar in Urology Department of Surgery & Cancer Imperial College London, UK

G a b rie l PR Bro wne MB BCh BAO DA(UK) FRCA FFICM

Consultant in Anaesthesia & Intensive Care Medicine Royal Marsden Hospital NHS Trust, London, UK

Ja ne V. Bo rle y BSc MBBS MRCOG

Clinical Research Fellow Imperial College London, UK

Jo hn Butle r MBBS BSc MRCOG

Gynaecological Oncology Fellow St. Bartholomew’s and Royal Marsden Hospitals London, UK

Jo hn H. She phe rd FRCS, FRCOG

Consultant Surgeon/Gynaecological Oncologist, Royal Marsden Hospital, London Hon. Consultant Gynaecological Surgeon, St. Bartholomew’s and Royal London Hospital

Justin Va le MS FRCS

Reader in Urology and Consultant Urological Surgeon Department of Surgery & Cancer Imperial College London, UK

Ma rc us E. Se tc he ll CVO MA MB BCh (Cantab) FRCS (Eng & Edin) FRCOG

Consultant Obstetrician & Gynaecologist King Edward Vll Hospital, he London Clinic and Portland Hospitals, London Hon. Consultant, St. Bartholomew’s, Homerton and Whittington Hospitals, London, UK

Ma rtin G o re PhD FRCP

Consultant Medical Oncologist Medical Director Royal Marsden Hospital London, UK

Contributors

Me la nie EB Po we ll MD FRCR FRCP

Consultant Clinical Oncologist, St. Bartholomew’s Hospital Honorary Clinical Senior Research Lecturer, Barts Cancer Institute, London, UK

Millie B. Lig ht MBChB (Edin) MRCP FRCR

Specialist Registrar in Clinical Oncology St. Bartholomew’s Hospital London, UK

Ro dne y H. Re zne k MA MB.chB FRANZCR (Hon) FFR RCSI (Hon) FRCP FRCR

Emeritus Professor of Diagnostic Imaging Barts Cancer Institute, Barts and he London School of Medicine and Dentistry Queen Mary University of London, UK

Ta riq Miskry MBBS MRCOG

Consultant Obstetrician & Gynaecologist St. Mary’s Hospital Imperial College NHS Trust London, UK

To m Se tc he ll BMBS MRCOG

Consultant Obstetrician & Gynaecologist St. Mary’s Hospital Imperial College NHS Trust London, UK

Va rune e Wira sing he MB BChir (Cantab) MA FRCA (London)

Specialist Registrar Anaesthetics, Hammersmith Hospital & Queen Charlotte’s and Chelsea Hospital Imperial College NHS Trust

Pa ul Ziprin MD FRCS (Gen Surg)

Senior Lecturer and Consultant Surgeon Department of Biosurgery & Surgical Technology Faculty of Medicine, Imperial College London, UK

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C o nte nts

Preface ______________________________________________________________________________________

v

Contributors _________________________________________________________________________________

vii

section A C ha pte r 1

Intro duc tio n, Surg ic a l Ana to m y, Pre - o pe ra tive Dia g no sis a nd Pa tie nt Ma na g e m e nt, Im a g ing , Le a rning the Skills, Po sto pe ra tive C a re Wo m e n’s He a lth Ne e ds in a G lo b a lly C ha ng ing So c ie ty ________________________

3

Marcus E. Setchell C ha pte r 2

Surg ic a l Ana to m y

____________________________________________________________

11

Christopher N. Hudson C ha pte r 3

Pre - o pe ra tive Asse ssm e nt a nd Dia g no stic Pro c e dure s __________________________

29

Marcus E. Setchell C ha pte r 4

Im a g ing in G yna e c o lo g y ______________________________________________________

39

Anju Sahdev, Rodney H. Reznek C ha pte r 5

Le a rning Ba sic Surg ic a l Skills ___________________________________________________

61

Christian Barnick, Caroline E. Everden C ha pte r 6

Po sto pe ra tive C a re a nd Pre ve ntio n o f C o m plic a tio ns ___________________________

73

Claire Mellon, Emma Kirk

section B C ha pte r 7

Be nig n C o nditio ns: The C e rvix, Va g ina a nd Vulva , Ute rus, O va rie s a nd Fa llo pia n Tub e s C e rvix, Va g ina a nd Vulva _____________________________________________________

81

Carl Chow C ha pte r 8

C o ng e nita l Ano m a lie s o f the G e nita l Tra c t _____________________________________

103

Adam Balen C ha pte r 9

The Ute rus _____________________________________________________________________

131

Tom Setchell, Tariq Miskry C ha pte r 10

The O va rie s ___________________________________________________________________

195

Jane Borley, Alan Farthing C ha pte r 11

Endo m e trio sis _________________________________________________________________

201

Alan Farthing, Jane Borley C ha pte r 12

The Fa llo pia n Tub e ____________________________________________________________

207

Colin Davis, Christine Deguara

section C C ha pte r 13

Uro g yna e c o lo g y a nd the Pe lvic Flo o r Stre ss Urina ry Inc o ntine nc e ____________________________________________________

241

Dudley Robinson C ha pte r 14 4

Pe lvic O rg a n Pro la pse _________________________________________________________

Clive Spence-Jones

259

Contents

section D G yna e c o lo g ic a l C a nc e r Surg e ry C ha pte r 15

Vulva l a nd Va g ina l C a nc e r____________________________________________________

279

John Butler, John H. Shepherd C ha pte r 16

Ute rus a nd C e rvix C a nc e r _____________________________________________________

293

John H. Shepherd C ha pte r 17

O va ria n a nd Tub a l C a nc e r ____________________________________________________

321

John H. Shepherd

section E C ha pte r 18

Aspe c ts o f Multidisc iplina ry C a re in G yna e c o lo g y Ra dio the ra py in G yna e c o lo g y _________________________________________________

337

Melanie Powell, Millie Light C ha pte r 19

Me dic a l O nc o lo g y in G yna e c o lo g y ____________________________________________

343

Axel Walther, Martin Gore C ha pte r 20

Aspe c ts o f Ana e sthe sia a nd C ritic a l C a re fo r G yna e c o lo g ic a l Surg e ry __________

355

Varunee Wirasinghe, Gabriel Browne C ha pte r 21

G yna e c o lo g y a nd the Uro lo g ist ________________________________________________

363

Erik Mayer, Justin Vale C ha pte r 22

G yna e c o lo g y a nd the G I Surg e o n _____________________________________________

391

Bhavna Gami, Paul Ziprin C ha pte r 23 3

C o nse nt to Tre a tm e nt— A Pe rso na l Vie w: A Pre - surg ic a l Fo rm a lity o r the C rux o f Do c to r–Pa tie nt Re la tio nship? _______________________________________

411

Bertie Leigh

Index________________________________________________________________________________________

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419

SECTION

Intro duc tio n, Surg ic a l Ana to m y, Pre - o pe ra tive Dia g no sis a nd Pa tie nt Ma na g e m e nt, Im a g ing , Le a rning the Skills, Po sto pe ra tive C a re SEC TIO N O UTLINE 1. Wo me n’ s He a lth Ne e d s in a G lo b a lly C ha ng ing So c ie ty ... 3 2. Surg ic a l Ana to my ... 11 3. Pre -o p e ra tive Asse ssme nt a nd Dia g no stic Pro c e d ure s ... 29 4. Ima g ing in G yna e c o lo g y ... 39 5. Le a rning Ba sic Surg ic a l Skills ... 61 6. Po sto p e ra tive C a re a nd Pre ve ntio n o f C o mp lic a tio ns ... 73

A

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Wo m e n’s He a lth Ne e ds in a G lo b a lly C ha ng ing So c ie ty

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Marcus E. Setchell

Intro duc tio n The scope and role, as well as the techniques, of gynaecological surgery have changed radically since the previous edition of this book in 2001, and much of it beyond recognition since the first edition in 1954. More importantly, the increased educational opportunities for women all over the world have widened their options to become included in all aspects of professional and working life, in addition to, or in place of, their more traditional roles as wives, mothers, child raisers and home providers. Women’s healthcare formerly consisted largely of pregnancy and labour care, and treatment for major health and lifethreatening gynaecological disorders. It now extends to all stages of life from pre-conception to old age. No longer is gynaecology predominantly a surgical speciality; it involves many disciplines including doctors from allied specialities, nurses, midwives and physiotherapists, all contributing their important, differing skills to provide complete healthcare for women at different stages of their lives. Prevention and screening, counselling, diagnostic tests, medical treatments and minimally invasive surgical and radiological procedures are all crucial components, in addition to both new and established gynaecological surgical procedures. Priorities and the patterns of care required in different parts of the world vary widely. Cultural and religious differences may greatly influence the kind of healthcare that is appropriate in some communities and not in others. Along with their midwifery colleagues and general practitioners, obstetricians have a major part to play in women’s healthcare from pre-conception through early embryonic and fetal life, up to and beyond the birth of a baby. Gynaecologists’ services may be required in childhood and adolescence, through to the reproductive years, where there may be considerable health needs in relation to contraception, infertility and early pregnancy failure. Young and middle-aged women may develop menstrual problems and disorders, as well as cancers and pelvic floor problems. Many of these gynaecological problems are particularly prevalent in the peri-menopausal years, and many women will need care and advice in a normal physiological menopause. The post-menopausal years see a different spectrum of disorders requiring specialist gynaecological care. Some of these problems may occur into advanced old age, completing the lifespan provision of care that is required.

He a lthc a re Re q uire m e nts a nd the Life C yc le PRE- C O NC EPTIO N AND PRE- NATAL It is a sad fact that in many parts of the world the female embryo/fetus is at greater risk in utero than the male, as a result of pregnancy termination on grounds of gender. Whilst this is illegal in many countries, in others there is a brisk trade in early detection of gender by ultrasound or chromosomal testing, followed by termination if early pregnancy diagnosis has revealed that an unfavoured gender is present. Advances in in vitro fertilisation (IVF) and pre-implantation genetic diagnosis now allow gender determination at a four-cell embryo stage; the desired gender embryo can be selected and implanted, and the remaining ones disposed of. Whilst this may be repugnant to some, in those societies where a woman will be pressurised into very high parity in order to achieve the desired sex, there may be a place for this to protect the health of the woman and prevent a potentially very large family, which the parents neither want nor can afford. Fetal medicine specialists may diagnose clinical conditions in utero, with particular implications for women, such as Turner’s syndrome (45 XO) and triple X condition (47 XXX) chromosomal disorders, as well as structural abnormalities. Some developmental and anatomical abnormalities diagnosed in utero will require specialised interventional procedures prior to birth, or consideration of the need for pregnancy termination.

INFANC Y AND C HILDHO O D Apart from the obvious responsibilities of the obstetrician at instrumental deliveries and Caesarean section, and to deal with emergency complications at delivery and in the early neonatal period, not uncommonly an additional gynaecological surgeon is required to assist in the control of serious post-partum haemorrhage, and/or uterine rupture and other genital tract trauma. Exceptionally, a paediatric gynaecologist may be needed in the early neonatal period in cases of indeterminate gender or other lower genital tract anomalies. In childhood, the gynaecologist may be required to deal with minor vaginal infections, and help with the diagnosis and removal of foreign bodies placed in the vagina. Sadly, there has been an increasing

Section A | Introduction, Anatomy, Pre-op. Diagnosis and Management, Imaging, Skill Learning, Postop. Care need for gynaecologists with paediatric experience to examine and counsel girls who may have been victims of sexual abuse. Less often, they may need to deal with the physical trauma that has been inflicted, as well as the psychological aftermath.

PUBERTY AND ADO LESC ENC E Puberty occurs earlier in girls than in boys. Geographical variations in the age of onset may be more related to environmental conditions and diet than ethnic characteristics. The puberty growth spurt occurs at a younger age in females than in males, and growth continues throughout adolescence to womanhood. Age of onset of menstruation is quite variable, but anywhere between the ages of 10 and 16 years is normal. In the absence of other clinical symptoms or signs, it is not usually appropriate to investigate primary amenorrhoea before the age of 16, unless there is absent development of secondary sexual characteristics. Precocious menarche does require investigation by a paediatric endocrinologist and/or gynaecologist, and any vaginal bleeding in infancy must be taken seriously to determine whether there has been any local trauma or possibly one of the rare varieties of genital malignancy. Throughout the world there are wide variations in what is considered to be the appropriate age for a young woman to commence intercourse, and differences exist in the legal age for marriage. In many western countries, there has been a notable decrease in the age of first intercourse, and with it an increase in the incidence of both teenage pregnancy and sexually transmitted diseases in teenagers. Consequently, much attention has been given to sex education in adolescence and childhood, requiring judicious and sensitive advice on contraception and the prevention of transmission of sexually transmitted diseases. More recently, the advent of human papilloma virus (HPV) vaccines has opened up a whole new vaccination programme for young girls to reduce the incidence of HPV infection and the potential risk of development of pre-malignant and malignant change in the vulnerable transformation zone of the cervix. The high incidence of termination of pregnancy in teenage girls remains a cause for concern. Conversely the availability of termination provides a preferable alternative for some to the educational and social problems that so often ensue when very young girls become mothers. Dysmenorrhoea and menorrhagia occurring in adolescence are other problems requiring expert care from either general practitioner or gynaecologist. Weight-related amenorrhoea appears to be an increasing problem, requiring multidisciplinary care over a long period. Obesity in the young is recognised to have many adverse health effects, and may be a factor in the frequent occurrence of polycystic ovary syndrome. In some communities, ritual mutilation of the female genitalia (female circumcision) is still practised and this is now a matter of serious worldwide concern. In many countries, performance of these procedures is illegal, whilst in others the strength of ancient custom rules, and the practice continues whether or not it is legal. The procedure varies from minimal

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labial trimming to full Pharaonic circumcision and infibulation. It is widely agreed that it is unethical for a medical practitioner to be involved in such a procedure, even though its performance under clinical conditions and anaesthesia can be considered ‘more humane’. Rather more controversial is the ethical position of a gynaecologist asked to recreate a woman’s anatomy to its circumcised state after childbirth or a gynaecological procedure. Fortunately, education and the spread of women’s groups that oppose the practice and support women in refusing to comply are slowly reducing this inhumane assault.

ADULTHO O D The twentieth century saw women in the western world fight and win many battles for equality, education and democratic rights, such that we now take for granted that women’s opportunities, expectations and achievements are equal to or exceed those of men. However, many modern women find themselves caught in the dilemma between the drive and desire to procreate within a relatively short biological time frame, and the expectation of themselves and from others to maintain their position in the workplace and society. Although in some countries, women’s place in society has advanced very little over centuries, in others there is a rapid catch up. A growing number of women quite reasonably choose to delay pregnancy until well into the third decade, with considerable consequences. Apart from needing prolonged contraception, fertility will be gradually declining, and there is the opportunity for gynaecological problems (such as endometriosis and fibroids) to develop. Pregnancy risk factors (such as miscarriage, chromosomal defects and pre-eclampsia) increase, and general health risks (such as obesity, hypertension, smoking, etc.) have longer to develop. Gynaecologists and healthcare planners must take into account the effect this has on healthcare needs of women and adapt services accordingly. Fortunately, many developments in Gynaecology that have taken place in recent years, such as diagnostic tools that provide more accurate and earlier diagnosis, minimally invasive treatments, greater understanding of infertility, and assisted conception help to counteract some of the potential problems created by modern life.

Changing Attitudes to Gynaecological Surgery Gynaecologists must expect and welcome that adult women attending a Gynaecology clinic today are more aware of their aspirations and expectations in relation to treatment and outcome, and expect to be fully informed about choices available to them. Conditions for which they attend may include quality of life disorders such as menorrhagia and dysmenorrhoea, or pre-menstrual symptoms. At the other end of the spectrum, some of them will have malignant or pre-malignant conditions. Whatever the nature of their gynaecological problem, in this age group, they are likely to be concerned about any likely consequences on their reproductive potential.

Women’s Health Needs in a Globally Changing Society Women have always regarded femininity as a visual image. Thus, the impact of disfiguring procedures or events has always been severe; extreme in the case of the face or breasts, but, to a lesser extent has also involved the vulva. Now, however, to a much greater extent, women focus upon the integrity of their internal organs. In some cultures, continued menstruation is an important outward sign of femininity so that even abnormal menstruation may be preferred to hysterectomy. In others, menstruation holds no such social significance and its cessation may actually be welcomed. To some, the ‘womb’ may become the object of blame for a perception that life is less than perfect, or even a result of a psychosexual aberration. The sympathetic gynaecologist needs to be alert to the full potential range of attitudes which can colour an individual’s approach to serious, trivial or even imagined problems of the upper genital tract. A very significant attitudinal change has been towards the gonads. Males have always been fiercely protective of their gonads as a visible part of the image of masculinity. In women, however, gonadal ablation has in the past been treated in a very cavalier fashion. Even the terms ‘uterine appendages’ or ‘adnexa’ tend to trivialise structures which may be removed during the operation of hysterectomy at the whim of the surgeon, particularly if it is known that future reproduction is not desired. Many women now are as protective of their internal gonads as are males of theirs. The preservation of all aspects of ‘femininity’, which is sexual function, menstruation, fertility and hormonal function, are of fundamental importance whether medical or surgical gynaecological care is being given. The issue becomes more complex in the presence of benign ovarian pathology, such as ovarian endometriosis, which may not have been suspected prior to surgery. The clinical circumstances surrounding advice for ovarian removal or conservation are discussed in Chapter 10. Whereas unilateral or partial oophorectomy may be a reasonable ad hoc response to an unexpected finding of ovarian pathology; it must be apparent that total removal of all functional ovarian tissue cannot, under any circumstances, be regarded as a mere encore to some other pelvic procedure. It is a serious step which should be the subject of explanation, discussion and documented consent. Many women will have just as strong feelings about the integrity of the uterus, even if they have no further desire for pregnancy. Hysterectomy is rightly perceived as the last resort, when more conservative treatments have been tried and failed. If there is any possibility that a planned conservative operation (e.g. myomectomy or widespread endometriosis) could necessitate hysterectomy, prior explanation and consent are essential. Giving information about a remote risk of damage to the uterus in such operations as pregnancy termination or uterine ablation should be given in a different and less alarming form. By the same token, a woman’s perception of her external genitalia and the role of the clitoris should be acknowledged; clitoral sparing procedures may sometimes be included in partial vulval resections for conditions short of invasive malignancy.

Infertility and Assisted Conception If pregnancy has been delayed, whether because of career, late partnership or economic reasons, once a couple want to start a family, it becomes a matter of urgency. The old management of waiting for two years before initiating investigation is inappropriate in a woman in her late thirties. Developments in assisted conception have rendered tubal surgery almost obsolete. Whilst these advances benefit many, they come with considerable cost. Governments and those commissioning healthcare have to make difficult decisions in deciding priorities for healthcare spending, and inevitably such decisions vary in different parts of the world. Pressure groups perceive access to expensive infertility treatments as a right, and when there are regional differences in provision and free access within the same country, this is seen as an unacceptable inequity. As the techniques of assisted reproduction have widened beyond the bounds of basic treatment for the infertile, difficult ethical issues have arisen which need to be thoroughly explored. The use of ovum donation in post-menopausal women well into their fifties and above is just one of the controversial aspects which arouse heated debate. Cryopreservation of oocytes (egg freezing) which was originally seen as a treatment to help a small group of young women whose ovarian function was going to be destroyed by cancer treatment is now seen as something that many young women will consider in their twenties and early thirties, if they have yet to find their ideal partner. It is necessary to have a legal framework, within which there is sufficient flexibility to allow reasonable future developments and yet ensure that morally and ethically unacceptable procedures are prevented.

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Parity Changing social custom in relation to partnerships and marriage as well as career aspirations of women have led to delay in elective childbearing, which tends to be clustered in the late twenties and early thirties over a relatively short time span. This means that there is a ‘time window’ during which gynaecological pathology may arise before ambitions of childbearing have been realised. The problems of teenage and unwanted pregnancy, however, remain and are reflected in an increased demand for pregnancy termination (see Chapter 9) including the more difficult terminations in the mid trimester. Most European countries have seen a striking reduction in family size, and many are no longer maintaining their population numbers. There are a number of contributory factors, including later age of first pregnancy, increased use of contraception and sterilisation, and an increase in the incidence of sub-fertility. In today’s over-populated world, good provision of contraception globally is of profound importance to prevent poverty and improve the health of women and children. In many westernised communities, grand multiparity is rare. Grand multiparity brings with it its own risks in pregnancy, as well as a tendency to certain gynaecological conditions. The 5

Section A | Introduction, Anatomy, Pre-op. Diagnosis and Management, Imaging, Skill Learning, Postop. Care urogenital hiatus is divaricated with concomitant pelvic floor relaxation, which often leads to uterine descent, which in turn may progress to vaginal extroversion with uterine procidentia (see Chapter 14). Moreover, peri-menopausal menorrhagia is common in women of higher parity due to myohyperplasia of the uterine muscle (at one time referred to as chronic sub-involution). The combined effect of multiple childbearing and excessive menstruation makes anaemia highly prevalent in this group. In many communities, grand multiparity is a reflection of poor socio-economic status with a high infant mortality and a perceived need to produce a large family. In such cases, the woman approaching the menopause will show signs of physical and psychological ‘wear and tear’ out of proportion to her age. Where grand multiparity is of cultural origin in a relatively affluent society, this effect may not be seen, although the anaemia from menstrual dysfunction may well still be a problem.

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MENO PAUSE

6

The menopause is a critical landmark in a woman’s life and the average age is now around 50. Those with an early menarche tend to have a delayed menopause and this may possibly be a risk factor for endometrial and ovarian cancer. Women with fibroids also tend to have a delayed menopause. The menopause is a subject of a great deal of myth and misunderstanding. Women themselves, and all healthcare professionals who deal with them, should have a clear appreciation of what may be classed as a normal menopause, namely either abrupt cessation of menstruation or progressively diminishing flow, or a progressively lengthening interval between otherwise normal menstrual episodes. The practice of labelling aberrations of menstruation during the climacteric as ‘merely the change’ is dangerous misinformation. Although the majority of such aberrations may have a non-sinister cause, failure to make a timely diagnosis of malignancy may ultimately prove fatal. The menopause is but one incident within the climacteric— the correct term for the time of life when ovarian function effectively ceases. The climacteric extends over a number of years and may be characterised by episodes of vasomotor instability, but there are hormone-related changes in a number of other body systems. Together with emotional changes, engendered by the clear demonstration of the end of the reproductive era, there are also likely to be social as well as somatic effects. The changes in the breasts and external genitalia are obvious but there is a tendency to ascribe all the contemporaneous changes of ageing to the climacteric (including the skin changes found equally in the ageing male!). To many, the menopause is an unwelcome reminder of the passage of time and the entry into a new phase of life. It is particularly resented if it is accompanied by severe menopausal symptoms of night sweats and hot flushes, along with fatigue and a reduction in energy. These symptoms may interfere with work and pleasure, added to which there may be a

reduction in libido. Little wonder that depression is a common occurrence at this stage of life, and that many women seek relief from these symptoms, either with naturopathic treatments or hormone replacement. Whilst some women will gain some relief from herbal and dietary remedies, oestrogen replacement is the only treatment which has been shown to relieve symptoms in controlled trials. However the waive of publications in the late 1990s and early part of the twenty-first century pointing out significant (if small) risks to health with prolonged usage of hormone replacement therapy (HRT), discouraged many women from using this effective treatment. More recent evidence has shifted opinion towards accepting that used for periods of 2–5 years, HRT is a beneficial and safe way to ameliorate the appreciable distress of the menopause.

PO ST- MENO PAUSAL YEARS AND THE EFFEC TS O F AG EING The climacteric and hormonal changes of course contribute to the process of ageing, although the latter continues well after the hormonal changes have settled to a steady state.

Urinary Function In the female, the lower urinary tract is supplied with oestrogen receptors and in common with other areas, shows climacteric as well as ageing effects. Over time, there is a reduction in turgidity and elasticity of the proximal urethra and bladder neck, leading to a measure of urethral sphincter incompetence (see Chapter 13) for which, under appropriate circumstances, HRT may offer some benefit, and pelvic floor physiotherapy often results in dramatic improvement. Bladder detrusor overactivity, however, increases with age in both sexes. The impact on continence in the female is correspondingly greater, and the inconvenience and embarrassment of frequency and urgency is not likely to be tolerated in today’s society which has an expectation of health and activity into the seventh and eighth decade. These problems may be compounded naturally by the effects of pelvic relaxation.

Pelvic Floor Relaxation The aetiology of uterovaginal prolapse and pelvic floor laxity is multi-factorial. Nulliparous uterine prolapse does occur, usually in older women during the climacteric, but primacy in aetiology must go to childbirth injury (see Chapter 14). The effects of childbirth damage may not be felt for some decades and the precipitating factor may be a structural change in collagen, associated with ageing and with the hormonal changes of the climacteric. The role of constipation and chronic straining at stool as a causation factor is under-appreciated. So many women relate the onset of constipation to pregnancy that this factor tends to be ignored. Insufficient emphasis has been placed upon the importance of re-establishing a normal bowel habit after childbirth.1 The penalty for this neglect may be felt many years

Women’s Health Needs in a Globally Changing Society later. Chronic straining not only imposes recurring mechanical damage to the pelvic support, but also may induce a traction neuropathy and in extreme cases both rectal prolapse and incontinence. This distressing symptom may not be primarily a gynaecological problem, but the gynaecological component is regrettably all too frequently ‘conveniently overlooked’.

Coitus: Dyspareunia/Apareunia No assumptions about age and continuation of sexual activity are justified. Women today feel much more able to discuss this openly and so should gynaecologists and general practitioners, but with tact and sensitivity. No surgical intervention likely to impair this should be undertaken without appropriate and sympathetic prior discussion (see Chapter 14). Ageing and the climacteric, however, may induce changes which provoke dyspareunia or even apareunia. Shrinkage may affect not only the vestibule but the vagina. Atrophy of the epithelium leads to thinning, fragility and soreness, producing painful fissuring of the fourchette and navicular fossa which splits each time that intercourse is attempted, aggravated by the deficiency in lubrication. These changes can be readily reversed by the use of local vaginal oestrogen for a 2 week course, and healthy vaginal skin maintained with use once or twice weekly. It should be remembered that dyspareunia is not invariably age related and it can occur in women of all ages. Lichen sclerosus et atrophicus may cause severe dyspareunia, culminating in the classical appearance of ‘keel shaped’ vulva with absence of the labia minora. Conversely, severe vulval pain and tenderness (vulvodynia) may be associated with minimal atrophic changes (vulvar vestibulitis) (see Chapter 7).

Osteoporosis Perhaps the most important metabolic change associated with the climacteric is osteoporosis. Although osteoporosis does occur in males, the sex ratio is heavily biased against women. Bone density studies show that in susceptible individuals, bone loss can begin before any other symptoms of the climacteric are present, and family history in this context is important.2 Both public and professional awareness of the condition is relatively recent including appreciation of the risk to life and health, not just from a propensity to limb fractures, but from collapse of the spine with serious compromise of function of intrathoracic and intra-abdominal organs. As screening for osteoporosis becomes more readily available, it is often appropriate for the gynaecologist to initiate this, especially in the context of a Menopause Clinic. Although treatment is predominantly with calcium, vitamin D and bisphosphonates, oestrogen therapy does still have a place and gynaecologists should have sufficient knowledge to discuss these matters.

Locomotor and Skeletal Changes In older women, the effects of osteoporosis detailed above may be added to the effects of age-related joint changes. Restricted

mobility of the hips may severely limit surgical access, but the importance of lack of mobility goes well beyond this, aggravating especially the effects of impairment of physiological functions and continence.

Other Endocrinopathy Thyrotoxicosis without other signs is an occasional source of confusion for cardiac problems. Of direct relevance to gynaecological practice, however, is the insidious onset of hypothyroidism, which may present with dysfunctional uterine bleeding. Not only would other attempts at hormonal manipulation with gestational steroids be inappropriate, but so also would surgery, which, together with anaesthesia, in the presence of uncorrected hypothyroidism is potentially dangerous. Type 2 diabetes needs to be borne in mind. On occasion, diabetes presents to the gynaecologist with a florid but typical vulvitis. The association of glucose intolerance with obesity is relevant. The concomitant enhancement of peripheral aromatisation of oestrogen precursors steroids is a risk factor for endometrial carcinoma.

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Gynaecological Cancers The post-menopausal years include the age group with the highest incidence of carcinomas of the endometrium, ovary and vulva. Most non-gynaecological cancers are also age related, so it behoves the gynaecologist to have a high index of suspicion when dealing with patients at this stage of life, and to enquire about weight loss, abdominal symptoms and bowel function. Assessment of the patient’s physical and mental state of health will be of great importance in selecting treatment appropriate for her. Many older patients are remarkably robust today and their views must be taken into consideration just as for younger women. For example, an 85-year-old patient asked to delay her operation for carcinoma of the endometrium until the tennis season was over as she had some important matches to play; she went on to have four more good seasons postoperatively.

C ha ng ing Ro le o f G yna e c o lo g ists Historically, the first successful abdominal operation was ‘ovariotomy’ or removal of an ovarian cyst3 and gynaecological surgery historically developed a long tradition of genital tract ablation. Surgery is only one element of the therapeutics of women’s health problems and non-surgical treatments of many conditions, such as endometriosis, fibroids, infertility and dysfunctional uterine bleeding play an increasingly important part. These non-surgical treatments include drugs, physiotherapy, radiological interventions, and involve many other specialists, including radiotherapists, oncologists and endocrinologists (Table 1.1).

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Section A | Introduction, Anatomy, Pre-op. Diagnosis and Management, Imaging, Skill Learning, Postop. Care Table 1.1:

1

Non-surgical options

Dysfunctional uterine bleeding Gestogens Haemostatic therapy (tranexamic acid) GnRH agonists Mirena IUS

Endometriosis GnRH agonists Progestogens Danazol

Stress urinary incontinence Physiotherapy Pessaries (rings, cubes and shelf) Biofeedback

Genital prolapse Pelvic Ńoor physiotherapy Per-urethral injections Electronic pessaries

Fibroids Uterine artery embolisation Magnetic resonance-guided focussed ultrasound

Pelvic cysts/abscesses Ultrasound-guided aspiration

Dia g no stic De ve lo pm e nts The precision of modern surgery has been greatly enhanced by the accuracy of pre-operative diagnosis, provided by both imaging and endoscopic techniques. Ian Donald,4 in the face of professional scepticism, pioneered the introduction of diagnostic ultrasonography, now an everyday tool of both radiologists and gynaecologists. CT scanning, magnetic resonance imaging and Positron emission tomography scans have further improved the accuracy of diagnosis. More recently, interventional procedures have been devised for use under the control of such techniques. The scope of interventional radiology now is outlined in Chapter 4.

Mo de rn De ve lo pm e nts

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One of the most significant developments over the last 10–20 years has been the increasing sub-specialisation within Gynaecology. Most hospitals are now staffed with one or more specialists in gynaecological cancer, urogynaecology and the pelvic floor, reproductive medicine (infertility), minimal access surgery and colposcopy. Some will have separate medical gynaecologists, paediatric and adolescent gynaecology specialists, and community gynaecologists (termination of pregnancy and contraception). A few have a sub-specialist for fibroids or endometriosis. The patient has the benefit of truly expert care, but there is a danger that she is not treated as a whole person, but rather as a condition going through a process of treatment. Another major change has been the switch from open laparotomy for gynaecological operations to laparoscopic procedures and more recently the introduction of robotic surgery (see Chapter 17). Although investigational and operative endoscopy has long been utilised in the bladder, the thorax and the alimentary canal, the potential for ‘peritoneoscopy’ was not picked up by general surgeons.5 In the gynaecological fraternity, Palmer,6 Steptoe7 and others, revisited and popularised the abdominal route for peritoneal endoscopy in the 1960s in preference to access via the pouch

of Douglas (culdoscopy) for which the knee chest position was normally required. The diagnostic and operative potential of intraperitoneal endoscopy was enhanced by the utilisation of a second portal for manipulation and diathermy. Second generation interventional endoscopy began with the perfection of camera and video technology with the surgeon now operating with a two dimensional screen using a range of instruments through two or more ports (see Chapters 3, 9, 10 and 11). Current technology provides visualisation enhanced by magnification of startling clarity and definition. As in macrosurgery, obesity, adhesions and haemorrhage can create difficulties which extend operating time considerably beyond that of conventional surgery. Hysteroscopic surgery has also prevented the need for more major procedures, and the various forms of endometrial ablation have diminished the need for hysterectomy. One of the consequences of the growth of sub-specialisation and the reduction in the number of open operations in benign gynaecology has been the loss of learning opportunities for trainees. Advances in anaesthesia (both regional and general), blood transfusion and antibiotics are all key innovations which have contributed spectacularly to the safety of surgery, thus permitting not only the development of major pelvic procedures but also to the restoration of function by time-consuming and complex reconstructive operations. These advances have occurred as a result of cross-disciplinary collaboration between modern surgical teams; the technical skills of urologists, colorectal surgeons and plastic surgeons may all be required together with the intensive care physician for postoperative management and the care of the critically ill patient.

C linic a l C o nside ra tio ns Many of the conventional procedures described in this book are now capable of being performed using minimally invasive techniques. These are presented together, but the selection of the actual procedure to be used must be individual both to the patient and her surgeon. For the former, the attractions of smaller incisions, less postoperative pain and quicker recuperation are obvious: an audit of both outcome and safety is less easily achieved. What is quite clear is that different manipulative skills are required for endoscopic surgery which must be taught and accredited (see Chapter 5) and that the skills and facilities for conventional open surgery must always also be available. The difficulties encountered are occasionally insuperable, requiring immediate reversion to open manual surgery. Finally, ambulatory care must not be equated with diminished surveillance in the postoperative period. Failure to recognise a complication at the time that such an event has occurred followed by premature discharge from hospital care, may mean that a complication which would be apparent in the early postoperative period, has been overlooked, with serious consequences.

Women’s Health Needs in a Globally Changing Society

Me a sure s o f O utc o m e PATIENT SATISFAC TIO N There is an increasing emphasis on the need for ‘an evidence base’ for any therapy or intervention, but the collection and appraisal of such evidence is not always easy. Randomised controlled trials provide the soundest basis but too frequently they are not available and indeed may not be appropriate, so that other ‘softer’ criteria have to be adopted. Because a procedure is time honoured this does not necessarily make it sound. For generations women have accepted the risks, disappointments and sequels of childbirth without complaint. Today, their expectations have markedly changed in relation both to reproductive and coital ability. Any surgical operation may be followed by a depressive illness. Surgical procedures which impact upon sexual and reproductive function have a particular propensity to generate reactive depression. Audit of results and patient experience surveys remain important measures of the success of a Department’s work.

reinforce the advice given, which should include instructions for medication, activity to be encouraged or avoided, expectations of pain and bleeding, return of normal bladder and bowel function, any special dietary requirements, as well as expected return to work, exercise and resumption of intercourse The intrusion of health economics into clinical care, long appreciated in the under-privileged Third World, has proceeded at pace in developed countries in the 1990s. In the last decade of the millennium, fuelled by the economic recession, elective surgery has been compartmentalised by ‘diagnosis-related groups’. This concept may make fiscal sense but is a move away from the individualisation of treatment which is the cornerstone of modern surgical management. It may also be specifically counter-productive in the care of malignant disease where there will be a hidden premium on under treatment if the provider of healthcare is liable to be penalised for increased length of stay. Similar economic considerations drive the demands of purchasers of healthcare for more and more minimally invasive surgery carried out on an office or ambulatory basis.

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PAIN RELIEF Just as anaesthesia revolutionised the scope and applicability of surgery, so has analgesia moderated the course of postoperative recovery. Pain appreciation is complex and the role of natural control mechanisms including endorphins is ill understood. Nevertheless, anaesthesia during operation clearly plays an important part in reduction of postoperative pain. A good anaesthetic reduces the trauma of access through the abdominal wall as well as influencing tissue oozing which can be responsible for bruising and haematoma formation, a very important cause for postoperative morbidity and pain. The length and depth of anaesthesia have obvious impact in their own right on the process of postoperative recovery. Some of the principles evolved in palliative care and the management of chronic pain have been adapted for short-term use in the control of postoperative pain. One of the principles seems to be that it is better to prevent pain than to treat established pain after a significant threshold has been reached. The use of ‘patient-controlled anaesthesia’ (PCA) using a manually operated pump has proved a popular advance (see Chapters 6 and 20).

PO STO PERATIVE C ARE Given the obvious advantages of shortened convalescence, it is not surprising that there has been a marked change in the way care is provided postoperatively. For the great majority of elective surgical procedures early mobilisation is practised with early discharge, graduated convalescence and early return to full normal activity and work. Day case and early discharge mean that the patient must absorb a great deal of information in a short time about their operation and recovery plans, perhaps while still under the effects of anaesthesia and analgesia. Leaflets may be needed to

C o nc lusio n All these changes coincide with, but are not driven by, improvement worldwide in the status of women. They also have happened at a time when rising costs of healthcare both in public and private healthcare have brought scrutiny and analysis of costs and benefits. Rationing of healthcare is an emotive subject but in one form or another is inevitable. If, however, the system stifles innovation and penalises excellence in subspecialisation and tertiary referral, the standards expected by the public of their medical and nursing care will not be maintained. The ‘changing ages of women’ and the multitude of technical advances present the gynaecological surgeon with everchanging challenges. The theme which emerges is that each woman is ‘her own person’ with individual hopes, fears, ambitions and views, all of which are deserving of respect and attention. This is what helps to make gynaecology such a fascinating speciality in which to work. It is the duty of the profession to audit performance and outcome measures against the background of quality assurance and the duty of the individual surgeon to ensure that his or her performance matches the standards set by the profession and society.

Re fe re nc e s 1. Hudson CN, Bowcock S. Constipation during and ater pregnancy. In: Kamm MA, Lennard Jones JE, eds. Constipation. Petersield Livingstone, 1993. 2. Slemenda C, Hui SL, Longcope C, Conran Johnston C. Sex steroids and bone mass. A study of changes about the time of the menopause. J Clin Invest. 1987;80:1261–8.

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Section A | Introduction, Anatomy, Pre-op. Diagnosis and Management, Imaging, Skill Learning, Postop. Care 3.

McDowell E. hree cases of extirpation of diseased ovaria. In: Society of Physicians, ed. he Eclectic Repertory and Analytical Review, Medical and Philosophical. Vol. VII, 1817, p. 242. 4. Willocks J. Ian Donald and the birth of obstetric ultrasound. In: Neilson JP, Chambers SE, eds. Obstetric Ultrasound. Oxford: Oxford University Press, 1993.

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5. Hosford J. Peritoneoscopy. Br Med J. 1948;2:348–9. 6. Palmer R. Instrumentation et technique de la coelioscopie gynecologique. Gynecol Obstet (Paris). 1947;46:420–31. 7. Steptoe PC. Laparoscopy in gynaecology. London: Livingstone, 1967.

Surg ic a l Ana to m y

2

Christopher N. Hudson

Most pathology can be considered as a distortion of normal anatomy and physiology. Consequently, those aspects of these subjects which are particularly relevant to the practice to gynaecological surgery may be considered as ‘applied anatomy and physiology’. Because the alimentary and urinary tracts leave the pelvis closely applied to the female genital tract, disorders of function with features common to all these are frequent. They are often associated with displacement or damage (from childbirth) to supporting structures. Such close anatomical relations also mean that intrinsic pathology in one organ may impinge on another in close proximity, presenting a challenge not only over diagnosis but for accurate and effective surgery. In this chapter, certain features of applied anatomy (including embryology) of the pelvis are highlighted by system and function. Embryology is relevant because it provides a comprehensible basis for several rather complex anatomical relationships (e.g. the rotation of the mid gut, and the formation of the inferior vena cava and iliac venous system) and also for a range of congenital abnormalities. Moreover, certain types of neoplastic alteration may, at least in theory, have an embryological basis.

G o na ds During the course of evolution, nature has tended to make use of structures which are currently effete having been evolved for more primitive use. For instance, the allantoic arteries, supplying the extra-embryonic ‘bladder’ or allantois, have become the umbilical arteries in placental mammals. Likewise, the left vitelline vein draining the extra-embryonic ‘intestine’ or yolk sac has become the umbilical vein. To the surgeon, the obliterated umbilical arteries (or lateral umbilical ligaments) are thus a useful guide to the superior vesical and uterine arteries. The duct system of the primitive kidney (mesonephric or Wolffian duct) becomes adapted to be the male gonadal duct system (vas deferens). The importance of the Wolffian duct in the female lies in its occasional persistence (as Gartner’s duct) which may course through the leaves of the broad ligament beside the cervix to an anterolateral position adjacent to the vagina. Mesonephric tubules, which in the male become epididymis and paradidymis, in the female may give rise to cystic structures adjacent to the ovary within the broad ligament (epoophoron and paroophoron) (Fig. 2.1). Very rarely, malignancy may arise

in such structures and, not surprisingly, may show Mullerian type differentiation. More commonly, benign cyst formation may enter the differential diagnosis of para-vaginal and paraovarian cysts. Pathologists have to beware lest the finding of unusual glandular inclusions of mesonephric type be wrongly ascribed to metastatic adenocarcinoma. The gonads in both sexes arise in the embryo in the paired gonadal or germinal ridges. These lie in close proximity to the nephrogenic ridge, which is represented by the transient pronephros and then the mesonephros. Germ cells, contrary to early teaching, do not arise in the gonadal ridge but appear very early in embryonic life at the root of yolk sac, from where they migrate laterally to the gonadal ridge. The root of the yolk sac is continuous with the dorsal mesentery, or coelomic fold, which envelopes the alimentary canal. Cranial to the umbilicus, there is a ventral mesentery as well, within which the liver develops. In both sexes, most tumours of germ cell origin arise within the gonads, with a similar range of pathological variants, although there are marked variations in both prevalence and biological behaviour. In the male, a teratoma is uncommon, usually solid and malignant, whereas in the female, benign cystic teratoma or dermoid cyst is one of the commonest neoplastic alterations found in the 20–40 years age group (Fig. 2.2). In both sexes, rare extra-gonadal germ cell tumours are found with a similar range of pathological variants. They arise in mid-line structures, from the pineal gland to the mediastinum, the liver and also the presacral region, where they may be overlooked on digital pelvic examination. In gynaecological practice, extra-gonadal malignant tumours of germ cell origin, particularly yolk sac tumours, may also arise within the Mullerian system (e.g. vagina, cervix and Fallopian tube).

O VARIAN SURFAC E EPITHELIAL DIFFERENTIATIO N Coelomic mesothelium which covers the gonadal ridge is immediately adjacent to that part of the coelom which has been invaginated to form the paramesonephric (Mullerian) ducts, which become the female genital tract. The paramesonephric ducts eventually differentiate into three classic types of epithelium, namely endocervical (mucinous), endometrioid (cubical glandular) and endosalpingeal (ciliated, serous

Section A | Introduction, Anatomy, Pre-op. Diagnosis and Management, Imaging, Skill Learning, Postop. Care Suspensory ligament of ovary (contains ovarian vessels)

Uterine (fallopian) tube Ampulla Infundibulum

Mesosalpinx (of broad ligament) Isthmus Epoophoron (Proper) ligament of ovary

2

Vesicular appendix (hydatid of Morgagni)

Fundus of uterus Fimbriae

Corpus luteum

Abdominal ostium

Ovary

Suspensory ligament of ovary

Body of uterus Mesometrium (of broad ligament)

Ovary Mesovarium (of broad ligament)

Ureter

(Proper) ligament of ovary

Uterosacral ligament

Uterine fallopian tube

Rectouterine pouch (cul-de-sac of Douglas) Fundus of uterus

la

pul

Am

Uterine ostium

Body of uterus Uterine port

us

Isthm

Infundibulum

Isthmus of uterus

(Proper) ligament of ovary

Internal os

Endometrium Myometrium Mesometrium (of broad ligament) Uterine vessels Cardinal (transverse cervical or Mackenrodt's) ligament

Cervix of uterus

Cervical canal with palmate folds

External os

Folds of uterine tube Fimbriae Suspensary ligament of ovary (contains ovarian vessels) Vesicular oppendix (hydatid of Morgagni) Epoophoron Follicle (graafian) of ovary Corpus albicans Corpus luteum

Vaginal fornix

Transformation zone

Vagina

Fig. 2.1: Uterus and appendages.

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and papillary). It happens that neoplasms arising from the surface epithelium of the ovary also differentiate along Mullerian lines to produce the common epithelial ovarian neoplasms. It is also considered that this surface epithelium may occasionally differentiate along Wolffian or mesonephric lines into transitional (urinary) epithelium, the resulting neoplasm being a Brenner tumour. However, similar islands of transitional type epithelium are commonly found on the broad ligament as Walthard’s rests.

G O NADAL MIG RATIO N The gonads develop in the loins. Gonadal migration in the male occurs along the course of the gubernaculum. This is interrupted in the female by the presence of the Mullerian system, so that the gubernaculum becomes the round ligament and the ovarian ligament. The anatomical relations of the round ligament to the inguinal canal are of surgical relevance.

Surgical Anatomy

Va g ina

Fig. 2.2: T2-weighted magnetic resonance scan showing uterus, bladder and benign cystic teratoma (dermoid cyst).

‘TESTIC ULAR’ PATHO LO G Y It is of direct gynaecological relevance in cases of hermaphroditism, gonadal dysgenesis and androgen insensitivity (testicular feminisation). The presence of a Y chromosome in dysgenetic gonads predisposes to neoplastic transformation either as a gonadoblastoma or frank invasive dysgerminoma.

The normal adult vagina is devoid of glandular tissue other than the Bartholin’s and minor vestibular glands. Very rarely, however, islands of Mullerian glandular tissue can rarely remain as rests within the vagina covered with squamous epithelium except for gland mouths. This is vaginal adenosis, a condition which occasionally occurs spontaneously, but has received attention as a sequel to maternal ingestion of a non-steroidal oestrogen (diethylstilboestrol) towards the end of the first trimester and early second trimester.1 There is an associated risk of development of mesonephroid (clear cell) adenocarcinoma of the vagina in adolescence and early adult life. The long axis of the vagina is slightly bowed posteriorly so that in the standing position, it is almost horizontal and apposed to the levator plate, an anatomical consideration which assumes importance in the management of vaginal extroversion and enterocoele.2 The uterine axis commonly approximates to a right angle from the vagina (anteversion). If the two have a common axis, the stage is set for prolapse. The vagina is normally flattened, the apex being ballooned by the vaginal portion of the cervix and in the lower part it is H-shaped due to the protrusion of the urethra (see Fig. 2.3). If, at childbirth, the introitus is stretched and part of the perineal body torn, gaping of the lowest part of the vagina occurs which may contribute, by removal of indirect support, to the progression of a genital prolapse, initiated by endopelvic fascial tears.

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Mulle ria n Syste m The development of the oviducts and uterus and the formation of the vagina are clinically relevant to the understanding of congenital abnormalities and to the pattern of cancer. The paired paramesonephronic ducts fuse from below upwards to form the vagina, cervix and uterine body. The vagina then solidifies and is replaced by an upgrowth from the urogenital sinus, the 5mb-vaginal bulb. The vagina eventually recanalises and is thus lined with stratified squamous epithelium which is not of Mullerian origin. This squamous epithelium will normally cover the ecto-cervix, as well as the vagina and its fornices. The junctional area between these two embryologically distinct varieties of epithelium is known as the transformation zone (see Fig. 2.1).

TRANSFO RMATIO N ZO NE The actual situation of the transformation zone is variable, both between individuals and at different epochs in reproductive life. Exposed glandular epithelium of Mullerian origin is susceptible both to infection and to damage by semen. Squamous metaplasia will occur, with new squamous epithelium growing in and displacing the original glandular epithelium. This is naturally an unstable area and it is not surprising that it is the seat of quite frequent neoplastic transformation.

Fig. 2.3: Horizontal section through mid-vagina, rectum and urethra. V, vagina; R, rectum; A, urethral rhabdosphincter; B, levator ani muscle; C, lateral ligament (pillar) of rectum; D, endopelvic (pre-rectal) fascia.

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If the cervix is pulled down with vulsellum forceps and the anterior vaginal wall put on the stretch, transverse grooves can be seen in the anterior vaginal wall.3 One indicates the upper limit of the bladder, while about 4 cm above the level of the external urethral meatus is a second groove and a third transverse groove lies just below the meatus. It has been suggested that the terms ‘bladder sulcus’, ‘transverse sulcus of the anterior vaginal wall’ and ‘submeatal sulcus’ should be used to describe these grooves. A small depression lies on either side of the meatus and a second depression lies on each side of the urethra. Between the submeatal sulcus and the transverse sulcus the vaginal wall is thrown into folds, which vary a great deal in development. If two fingers are passed along the posterior vaginal wall above the level of the levator ani muscles, a transverse fold, which is not particularly prominent, can usually be felt. The rectovaginal space lies immediately posterior to this fold.

C o ng e nita l Ab no rm a litie s Any degree of failure of Mullerian fusion is of clinical significance both obstetrically and for early reproductive performance (see Chapter 8). The extent may vary from complete reduplication (uterus didelphys) to a septate cavity (Fig. 2.4). Failures of vaginal recanalisation are complex and can be of considerable surgical importance. They need to be distinguished from a simple impervious membrane (imperforate hymen) (see Chapter 8). Failures of recanalisation are usually distal suggesting that the process does not necessarily take place from below upwards. In other words, if the lower vagina is absent there is almost always a small upper compartment into which the cervix projects.

More difficult to explain is the rare occurrence of cervical agenesis in which there is a functional uterine corpus attached to a blind upper vagina by only a fold of peritoneum.4 It must be assumed that the resorption process which is normal for the vagina has, on this occasion, involved the cervix as well. Vaginal recanalisation from the sinovaginal bulb has occurred as normal, but then failed to meet up with the lower margin of the uterus and thus create a transformation zone. Very rarely indeed the vaginal recanalisation process fails completely, resulting in a situation in which there is a small functional uterus without cervix or vagina. Combinations of these developmental anomalies are particularly testing. Rudimentary uterine horns may not be connected with the main cavity; nor is the anatomical situation easily elucidated with standard imaging techniques. These horns, however, are not exempt from embryo implantation and the natural history of the resultant ectopic pregnancy may be quite atypical. If the lower genital tract is reduplicated there is a number of clinically perplexing variants.5 The vertical septum may be so deviated to one side that the presence of the second vagina is completely overlooked. If, however, one vagina is distally occluded, unilateral haematocolpos will develop without the typical history of primary amenorrhoea (cryptomenorrhoea). Furthermore, if the distal half of one vagina is not patent, the resultant upper haematocolpos is easily mistaken for an intraperitoneal cyst impacted in the pouch of Douglas.

Uppe r Re na l Tra c t MESO NEPHRO S AND METANEPHRO S The relative importance of the primitive kidney system, associated collecting tubules and ducts has been referred to above. The definitive kidney or metanephros, develops as a paired organ and migrates to the loin, acquiring a relevant blood supply in which process numerous vascular anomalies may arise, some of which can interfere with ureteric function.

URETER The definitive ureter arises as a bud from the distal mesonephric (Wolffian) duct. This bud, the metanephric duct, grows in a cephalad direction to meet up with the relevant kidney (the metanephros) and join with the calyceal system. An error in this process will result in polycystic kidneys. The distal mesonephric duct itself becomes incorporated into the bladder base as the trigone; hence the separation of the terminal ureters and the ejaculatory ducts in the male.

EC TO PIC URETER Fig. 2.4: T2-weighted MR scan showing failure of Mullerian fusion. A single uterine body with twin cavities.

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There are various forms of ectopic ureter which are clinically important in the female with openings into the distal urethra, vagina, Gartner’s duct or even uterus.

Surgical Anatomy

C O NG ENITAL ANO MALIES These are of considerable relevance to the gynaecological surgeon not least because there is a well-recognised association between urinary tract anomalies and congenital anomalies of the Mullerian system. Rock and Jones6 described twelve cases of unilateral renal agenesis associated with reduplication of the Mullerian system with incomplete canalisation on one side resulting in unilateral haematocolpos. There are, however, other important variants of which the gynaecological surgeon should be aware as they frequently involve aberrant anatomy of the pelvic ureter, as well as giving rise to diagnostic confusion. Removal of a solitary pelvic kidney by an unwary gynaecologist is a recognised nightmare scenario and this differential diagnosis should always be borne in mind with any smooth retroperitoneal tumour. Conversely, the ureter may be duplicated in all or part of its course. The distal orifice of a duplex ureter may be ectopic. A ‘horseshoe’ kidney has many variants, the lower poles of the two kidneys often having a bar of tissue joining them at the level of the renal arteries. They may, however, lie at a much lower level within the pelvis and impinge on the area of gynaecological diagnosis. As stated, the course of the ureters will be deviant. The most aberrant course of a ureter will be found in the case of ‘crossed renal ectopia’ when both kidneys are to be found in one loin and usually joined together. The contralateral ureter has to cross the midline and the major vessels (Figs. 2.5 and 2.6). Another rare cause of aberrant ureteric course is the retro-caval ureter in which the right ureter is hooked around the inferior vena cava.

also rarely, malignant transformation of a persistent urachus can occur producing an adenocarcinoma at the umbilicus for which no other primary is found. Distally, the septum may be deficient so that the urethra appears to discharge into the lower vagina rather than on to the vestibule (hypospadias). Epispadias also occurs. The functional length of the urethra has relevance to continence and congenitally short urethra, therefore, may require surgical correction.

BLADDER AND URETHRA

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Supports and Attachments Only the superior surface of the bladder is covered in peritoneum. The vault below this level is surrounded by loose areolar tissue to allow the bladder to fill and empty. The principal fixation of the bladder is around the pedicle of the inferior vesical vessels and the bladder base sits on the endopelvic fascia. The pubocervical ligaments are condensations of this fascia; laterally, the loose tissue may be developed during surgery as the paravesical space (see the text below). The bladder detrusor muscle is not arranged in circular and longitudinal layers, but in an irregular spiral. There is no

RENAL TRANSPLANT Finally, the gynaecological surgeon should be aware that in patients who have undergone renal transplantation, the transplanted organ is to be found in one or other iliac fossae and should not be mistakenly diagnosed as a ‘gynaecological tumour’.

Ure thra , Bla dde r Ne c k a nd Exte rna l G e nita lia In both sexes, the cloaca is divided in the coronal plane by the urorectal septum. In the female, interposition of the Mullerian system and sinovaginal bulb means that abnormal communication between the alimentary canal and the urinary bladder is exceptionally rare. Congenital anomalies of the bladder are relatively few, the most important being associated with a deficient anterior abdominal wall and incomplete pelvic girdle (ectopia vesicae). In such cases, the clitoris and vulva may be bifid. The condition is of importance to gynaecologists for the associated uterovaginal prolapse. The allantois is the primordial ‘extra-embryonic bladder’. Its remnant is the urachus which becomes the median umbilical ligament (see Fig. 2.12). Rarely, the urachus may be patent at birth and leak urine into the stump of the umbilical cord and,

Fig. 2.5: Vaginal ectopic ureter associated with crossed renal ectopia. Ascending ureterogram achieved by catheterisation of an abnormal ureteric oriłce in the vagina. The ectopic ureter crosses the midline to a rudimentary lower pole of the left kidney which represents an ectopic right kidney.

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recognisable circular sphincter at the internal meatus but there is extra elastic tissue. Some of the detrusor fibres passing down the urethra will, when they contract, have a tendency to open the bladder neck (Fig. 2.7). Continence depends on maintenance of a pressure differential between the proximal urethra and the bladder. The urethral pressure is contributed by the urethral smooth muscle and by the rhabdosphincter. The rhabdosphincter is an intrinsic muscle which extends from the bladder neck. The sphincter is not symmetrical being considerably thicker anteriorly than on the vaginal aspect. The nerve supply is through the pelvic nerves rather than the pudendal. The urethra is suspended beneath the pubic arch by the paired pubo-urethral ligaments, sometimes termed the triangular ligament. In the female, this is separated by the vaginal sulcus from the rest of the bifid perineal membrane, which supports the distal quarter of the vagina (see Fig. 2.8). Just above the level of the triangular ligament, the urethra passes between the limbs of the levator ani (puborectalis) muscle. There are slips from the levator ani to the urethra

Fig. 2.7: Section of bladder neck and vagina. A, urethra; B, bladder (detrusor); C, post-urethral ligament, upper attachment of rhabdosphincter; V, vagina.

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Fig. 2.6: Vaginal ectopic ureter associated with crossed renal ectopia. The excretion urogram shows an apparently solitary kidney with a normally positioned single ureter. The degree of malrotation should give rise to suspicion of an anomaly, such as a non-functioning pole in a ‘horseshoe’ kidney.

Fig. 2.8: Horizontal section of the distal urethra and vagina. B, pubourethral ligament; C, cavernous tissue; V, vagina; D, vaginal wall tethered to perineal membrane (urogenital diaphragm).

Surgical Anatomy (extrinsic rhabdosphincter or compressor urethrae). This extrinsic rhabdosphincter contracts with the levator ani and mostly consists of ‘fast twitch’ fibres in contrast to the intrinsic muscle which is essentially ‘slow twitch’.7 The upward extensions of the pubo-urethral ligaments are the counterpart of the male puboprostatic ligaments. Laxity of the pubo-urethral supports can result in urethral hypermobility, an important factor in stress urinary incontinence (Fig. 2.8).

Ure te r Proficiency in identification and display of the ureter marks the skilled pelvic surgeon. Aside from the congenital abnormalities (see Figs. 2.5 and 2.6), the ureter has some fairly constant anatomical points. Between these its course may be distorted and deviated by pelvic pathology. At the pelvic brim the ureter crosses the iliac vessels close to their bifurcation and posteromedial to the ovarian vessels which have crossed above the brim. Below the pelvic brim the ureter is always closely related to the parietal peritoneum even when the para-rectal space is developed. For this reason, it is prone to adhere to cysts and abscesses which have become fixed to the side wall of the pelvis. The ureter converges towards, but does not reach, the uterosacral ligaments. It is therefore at risk from plicating sutures (culdoplasty). Where the pelvic peritoneum sweeps off the side wall to become the posterior leaf of the broad ligament, the ureter passes forward to lie over the cardinal ligament beneath the uterine artery. This is the commencement of the ureteric tunnel, which surrounds the ureter until it becomes intramural in the bladder wall. This tunnel requires release in all forms of radical hysterectomy. It will be found in the bladder pillar delineated once the vesico-cervical and para-vesical space have been developed (Fig. 2.9).

Fig. 2.9: The pelvic ureter. The ureter has been displayed during a radical hysterectomy operation. The broad ligament has been opened. The ureter, with its mesentery intact, lies on the medial leaf of the peritoneum. The obliterated hypogastric (umbilical) artery has been elevated and the uterine artery has been divided at its origin from the anterior division of the internal iliac artery.

Re c tum The rectum commences at the second piece of the sacrum. Peritoneum covers the anterior three quarters at the rectosigmoid junction but covers the front only at the level of the pouch of Douglas. The distal third has no peritoneal coat and this extra-peritoneal rectum is several centimetres long extending to the anorectal ring. Complete removal of the pelvic peritoneum at the time of radical oophorectomy involving rectosigmoid resection will therefore still leave sufficient bowel for a relatively straightforward anastomosis (see Chapter 17). The rectum is supported by lateral ligaments which contain the middle rectal artery. They can be divided when mobilising a short distal stump. They become attenuated in rectal prolapse which, in effect, begins as intussusception at the fundus of the peritoneal cul-de-sac.

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Ana l C a na l Angulation of the anorectal junction by the puborectalis muscle marks the upper limit of the ‘cylindrical’ anal canal (Fig. 2.10).

Fig. 2.10: Horizontal section between the vagina and the rectum just above the anorectal junction. V, vagina; R, rectum; A, apex of perineal body; C, outer longitudinal muscle of the rectum; E, inner circular muscle; O, levator ani (puborectalis).

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EXTERNAL ANAL SPHINC TER

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The classic subdivisions of the voluntary anal sphincter are deep, superficial and subcutaneous; the latter being puckered by the terminal strands of the longitudinal plain muscle. It is important to appreciate that in the female the anterior wall of the anal canal is significantly shorter than the posterior wall (the cylinder has been cut obliquely). There are no subdivisions of the anterior arc of the external anal sphincter in females (Fig. 2.11). The outline of an intact anal sphincter can usually be seen on perineal inspection. Appreciation of the asymmetric nature of the female anal canal is essential for the correct interpretation of physical signs and of transvaginal or per-anal ultrasound for the demonstration of the anal sphincters.8 The modern view regards the external anal sphincter as one muscle innervated by the pudendal nerve. The deepest part of this sphincter mechanism is continuous with the puborectalis sling of the levator ani muscle, and it is this muscle which provides the main element of control of defaecation; it is innervated directly from the sacral plexus. Fistula and sphincter injuries below this level produce impairment of continence of fluid faeces and flatus only, solid motions being controllable by the puborectalis alone. The key to this control is probably the angulation present at the anorectal ring. Sometimes the angle may be more acute on straining. When this occurs, evacuation of the bowel at defaecation may be incomplete, producing a vicious cycle of straining and pelvic floor inhibition, which leads to rectal prolapse as well as vaginal prolapse.

INTERNAL ANAL SPHINC TER In common with the rest of the alimentary canal, the plain muscle of the rectal wall consists of an inner circular layer and an outer longitudinal layer (see Fig. 2.11). There is also thin muscularis mucosae in the subepithelial space above the dentate line. A condensation of the lowest portion of the inner circular layer forms the internal anal sphincter. It is the position

of this muscle which has caused some confusion, not only because it extends proximally above the anterior arc of the external sphincter, but also because its lower free margin is a little way up the anal canal in the unanaesthetised patient (see Fig. 2.11). Under anaesthetic, however, the resting tone of the external sphincter is relaxed and the internal sphincter then apparently reaches to the anal verge. The intersphincteric ridge may be palpated quite easily. The outer longitudinal muscle distally receives a contribution from the levator ani (puboanalis) and obviously needs a point of attachment and in fact divides into several tails, which insert over a wide area mostly into the perianal skin. A lateral strand also separates the perianal space from the ischiorectal fossa9 with a forward extension tethering the internal anal sphincter through attachment of the longitudinal muscle to the perineal membrane at the apex of the perineal body. This tethering extends parasagittally and may be responsible for childbirth tears of the internal anal sphincter without necessarily the external sphincter being completely divided.

Pe lvic Fa sc ia a nd Endo pe lvic Fa sc ia The pelvic fascia is defined as the fascial tissue which covers the upper and lower surfaces of the levator ani muscles, together with the medial surfaces of the two obturator internus muscles. Between the pelvic fascia and the peritoneum above, all the loose tissues are best referred to as the endopelvic fascia. This fascia is condensed posterolaterally to form the uterosacral ligaments and laterally the transverse cervical (cardinal or Mackenrodt’s) ligaments. In addition, the vagina and cervix have their own fascial layer and the same remarks apply to the rectum, the bladder and the urethra. Furthermore, each of these is attached to adjacent organs and the pelvic side walls by pelvic fascia which can be recognised at operation. In the anterior compartment, this fascia is attached to a tendinous arc just medial to the attachment of the levator ani muscle to its own tendinous arc (white line) which is on the covering of the obturator internus muscle (Fig. 2.12). Tears of the endo-pelvic fascia are the initiating event for various types of vaginal prolapse.10

VESIC O VAG INAL SPAC E

Fig. 2.11: Sagittal section through the perineal body. V, vagina; R, rectum; E, external (striated) anal sphincter muscle; G, muscularis mucosae; B, internal (unstriated) anal sphincter; A, outer longitudinal rectal muscle, dividing into ‘tails’, passing to the vagina at (F) and the perineal membrane at (C), to which the vaginal wall is also tethered (D).

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Between the vesical fascia and the vaginal fascia, a plane of cleavage can be distinguished, known as the vesicovaginal space. This ill-defined space, bridged by delicate bands of connective tissue, can be demonstrated by dissection; it is relatively bloodless, and it is possible to separate the vaginal fascia from the vesical fascia by stripping, if the correct plane of cleavage is found. At the level of the transverse vaginal sulcus the vaginal fascia and vesical fascia fuse together so that there is no plane of cleavage below this level.3 The attachment is here to the triangular ligament or perineal membrane. The rugose projections on the anterior vaginal wall lie below this level, and intervening between the vaginal

Surgical Anatomy Umbilical prevesical fascia Occluded part of umbilical artery (medial umbilical ligament) Urinary bladder and vesical fascia Rectus abdominis muscle Superior vesicle artery in lateral ligament of bladder

Urachus (median umbilical ligament) Pubic symphysis Inferior (arcuate) pubic ligament Deep dorsal vein of clitoris Retropubic (prevesical space) Transverse perineal ligament (anterior thickening of perineal membrane) Medial pubovesical ligament Lateral pubovesical ligament Vesicocervical fascial fibers

Linea terminalis of pelvis Femoral ring Inferior epigastric artery Pubic branch

2

Superior fascia of pelvic diaphragm (superior levator ani fascia)

Deep inguinal ring Iliopubic tract

Obturator canal and obturator artery

Transversalis fascia

External iliac vessels

Femoral nerve (under fascia)

Deep circumflex iliac vessels Iliac fascia

Ovarian vessels in suspensory ligament of ovary Iliacus muscle Obturator internus fascia Tendinous arch of levator ani muscle

Ureter Psoas major muscle Internal iliac vessels Inferior vesical and vaginal arteries

Tendinous arch of pelvic fascia

Hypogastric (neurovascular) sheath

Sacrouterine ligament

Middle rectal artery Cervix of uterus and uterine fascia Superior rectal artery (left branch)

Cardinal (transverse cervical or Mackenrodt’s) ligament with uterine artery Vaginorectal fascial fibers

Rectum and rectal fascia Rectovaginal (potential) space Presacral (potential) space (spread open) Median sacral artery

Presacral fascia (pulled away) Anterior sacrococcygeal ligament Vesicocervical and vesicovaginal (potential) spaces

Fig. 2.12: Endopelvic fascia and spaces.

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wall and the fascia covering the urethra is cavernous tissue, which must be cut through with a scalpel when the vaginal wall is dissected from the fused vaginal and urethral fascia. The fused vaginal and urethral fascia forms a condensation of tissue which is attached laterally to each pubic ramus and extends from the bladder wall or urethrovesical junction to the urethral meatus. The ligamentous supports of the urethra, where it passes beneath the pubic arch, have been termed the anterior and posterior pubo-urethral ligaments.11 The latter are paired, the space between them transmitting the dorsal vein of the clitoris. Between these supports, and arising by the origin of the levator ani muscles on the body of the pubis, may be found the extrinsic rhabdosphincter or compressor urethrae.

VESIC O C ERVIC AL LIG AMENT At abdominal operations, if the uterus is pulled upwards a small V-shaped fossa can be seen on the anterior surface in the midline. Above this level, the peritoneum is firmly attached to the uterine muscle. Below the V, the peritoneum becomes detached from the front of the uterus. In most cases the upper curvature of the bladder can be seen through the peritoneum, and there is a space of at least 2 cm between the apex of the V and the limit of the bladder. Immediately beneath the peritoneum, passing from the bladder to the uterus is a thin layer of tissue, the vesicocervical ligament. It represents the upper limit of the vesicocervical space. The V-shaped fossa lies approximately at the level of the internal os. If during a vaginal operation the cervix is pulled down and the limit of the bladder exposed the same bands of tissue can be seen to pass from the bladder to the cervix. Three main condensations can be recognised; one is situated in the midline, while two lie laterally. The latter condensations are referred to as the pillars of the bladder. The midline condensation forms the vesicocervical ligament. The lateral condensations beneath the bladder pillars are the pubocervical ligaments which are the anterior limb of the transverse cervical or cardinal ligaments. The pubocervical ligaments are responsible for retaining the cervix and upper vagina within the anterior compartment of the pelvis. If attenuated or destroyed, they allow backward rotation of the whole vagina into the hollow of the sacrum (retrocession), a displacement which has to be distinguished from anterior vaginal wall prolapse (cystocoele), with which however it may be associated. Transverse cervical ligaments (cardinal ligaments). These ‘butterfly’-shaped ligaments lie in the base of the broad ligament. They are the principal support for both the uterus and the vagina. In the standing position, they lie almost vertically.12 The vaginal component (para-colpos) is variable and if it is deficient after hysterectomy, the stage is set for later vaginal extroversion. The posterior arcs of the cardinal ligaments are the uterosacral ligaments which embrace the rectum and the pouch of Douglas. Their close relationship to the ureter should be noted. 20

PO STERIO R C O MPARTMENT Above the apex of the perineal body, the rectovaginal space intervenes between the vaginal fascia of the posterior vaginal wall and the thin fascia covering the anterior surface of the rectum. When the pre-rectal fascia has been torn in cases of rectocoele, the anterior wall of the rectum presents as a layer of muscle slightly corrugated longitudinally with prominent vessels. At the apex of the space is the fascial layer (fascia of Denonvilliers’) which supports the peritoneum of the pouch of Douglas. It is, of course, deficient in cases of enterocoele.

REC TAL PILLARS Laterally, the rectal pillars merge with the lateral ligaments of the rectum which contain the middle rectal arteries (which are not always present). This fascial layer has to be penetrated to gain access to the sacrospinous ligament for sacrospinous colpopexy operations.

RO UND LIG AMENT AND ITS C O NNEC TIVE TISSUE MESENTERY The round ligament consists of unstriated muscle fibres arranged in a central thick core of longitudinal fibres separated by a connective tissue of collagen fibres with very little elastic tissue from an outer thin layer of muscle fibres running obliquely or longitudinally. If the round ligaments and the infundibulopelvic fold are divided, the uterus drawn over to the opposite side and the broad ligament opened up by blunt dissection, it is possible to identify a connective tissue mesentery passing from the round ligament downwards and inwards to become attached to the lateral side of the uterus anterior to the uterine vessels where it becomes continuous with the upward prolongation of the bladder pillar. The round ligament mesentery has no obvious function, but it is most helpful at hysterectomy for defining the situation of the uterine vessels. Moreover, when traced downwards and inwards it leads to the bladder pillar which can then be identified.

PARAVESIC AL AND PARAREC TAL SPAC ES At Wertheim’s operation a deep dissection is required. It will be found that the ureter passes through a canal in the cardinal ligament. The roof of the canal is formed by connective tissue which surrounds the uterine artery, while below the ureteric canal lies the main portion of the cardinal ligament. The paravesical space lies in front of each cardinal ligament and the pararectal space behind. These spaces can be recognised at operation and are easily opened up as they contain only very tenuous cellular tissue condensations.

PRESAC RAL SPAC E Within the posterior part of the pelvic cavity is a dense layer of fascia covering the anterior surface of the sacral plexus and the large vessels of the gluteal region. This fascia (Waldeyer’s fascia) must be divided in a posterior exenteration operation. To dissect in a plane posterior to this

Surgical Anatomy fascia is to invite major haemorrhage. There is a useful plane of loose areolar tissue immediately behind the rectum but in front of this fascia.

Musc ula r Pe lvic Dia phra g m The levator ani muscle, which is of great social and sexual significance, operates under two distinct disadvantages in the human, namely, walking upright (instead of ‘on all fours’) and the evolution of the human brain which requires delivery of a fetus with a large and disproportionately developed cranium. The urogenital hiatus is inevitably stretched or torn in childbirth and may never return to its pristine state. Much of the pelvic support provided to the pelvic contents in this large birth canal is dynamic. Pelvic muscular relaxation thus leads to undue stress and stretch on the fixed ligamentous and fascial supports of the uterus and vagina, which, in turn gives rise to prolapse (Fig. 2.12).

LEVATO R ANI MUSC LE Some authors maintain that the two levator ani muscles decussate and sometimes fuse together between the vagina and the rectum. Discrepancies may also be found in the descriptions in anatomical textbooks of the structure of the perineal body and of the sphincter muscles of the anus. Dissecting room subjects are of limited value for anatomical researches, as fixation, and even anaesthesia, can alter the relationship between muscular components, such as the external and internal anal sphincters. Modem imaging (endosonography and magnetic resonance) has helped to elucidate the area, but images have had to be validated by serial dissection and histological confirmation before interpretation can be secure (Fig. 2.13).13,14 The origin of the levator ani muscle is from a linear area on the posterior aspect of the body of the pubis close to but not reaching

2

Fig. 2.14: T2-weighted MR scan of the pelvic Ńoor showing the pubococcygeus and puborectalis muscles.

the midline, thus forming the base of the retropubic space. Posterolaterally, the origin is from the tendinous arc (white line) over the obturator internus muscle as far as the ischial spine (see Fig. 2.12). The pubococcygeus muscles are inserted into the coccyx and into the anococcygeal raphe. The puborectalis muscle, which is functionally very important, actually forms a sling around the anorectal junction from the body of one pubic bone to the other. Because of its firm attachment to the lateral vaginal wall, it acts functionally as a vaginal sphincter without actually encircling that organ (Figs. 2.13 and 2.14). In spite of this anatomical fact, if the patient is suffering from posterior vaginal wall prolapse and her levator muscles are divaricated, and the tissues which normally bind together the two levator muscles between the vagina and the rectum are either stretched or torn through, not only can a rectocoele be controlled if the two levator muscles are artificially brought together between the vagina and the rectum, but also anal sphincter function may be improved. The good results of a properly performed operation do not prove, however, that the two levator muscles normally decussate between the vagina and rectum, and over-zealous approximation of the pubococcygeus muscles can produce an ‘hour-glass’ stricture of the mid-vagina with resultant sexual dysfunction. The nerve supply to the levator ani muscle reaches the muscle on its visceral (pelvic) aspect. In cases of major pelvic floor descent, due to chronic straining, it is subject to traction neuropathy.15

Uro g e nita l Dia phra g m a nd Isc hio re c ta l Fo ssa Fig. 2.13: Muscular pelvic diaphragm as viewed from below after removal of the urogenital diaphragm. R, puborectalis; PC, pubococcygens; S, sacrospinous ligament; IRF, ischiorectal fossa.

In the female, the perineal membrane which covers the space beneath the inferior pubic rami is effectively divided into three parts by the vagina. The related superficial and deep perineal pouches may be found lateral to the lowest part of

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Section A | Introduction, Anatomy, Pre-op. Diagnosis and Management, Imaging, Skill Learning, Postop. Care the vagina, where the two halves of the perineal membrane itself provide lateral support. This area is exposed in radical vulvectomy.

ISC HIO REC TAL FO SSA

2

This important space is ineptly named. It is situated besides the anus, rather than the rectum, but separated distally by the perianal space. It is, however, separated from the ischium by the obturator internus muscle and the pudendal canal, and from the rectum by the levator ani muscle. Inferiorly, its medial wall is the anal canal and there is a communication between the two sides posterior to the anus, an anatomical arrangement which is important when abscess formation occurs. Communication anterior to the anal canal is, of course, blocked by the perineal body, of which the fossa is a lateral relation. Figure 2.15 illustrates the point that on each side the ischiorectal fossa has an anterior extension over the free posterior margin of the perineal membrane beneath the muscle of levator ani. Owing to the adhesion of levator ani to the lateral wall of the vagina, the ischiorectal fossa is close to the vagina at this level and collections of blood or pus may encroach upon the lumen and be palpated digitally. Such collections need to be distinguished from those in the para-vaginal space, which is cranial to the levator muscle.

PERINEAL BO DY The perineal body is a wedge-shaped body with its apex at the level of the perineal membrane where the two halves are attached to each other at the central point of the perineum immediately posterior to the lower end of the vagina. The apex fills the gap between the two halves of the puborectalis muscle between their encirclement of the anorectal junction and where they are adherent to the lateral wall of the vagina. The base is formed by the skin of the perineum extending from the posterior margin of the vestibule (navicular fossa) to the anterior anal verge. Various important structures impinge upon or participate in the perineal body. Functionally, the most important are the anal sphincter muscles.

The superficial transverse perineal muscle overlies the free posterior border of the perineal membrane and decussates with the superficial external anal sphincter (Fig. 2.16). The deep transverse perineal muscles occupy a pouch adjacent to the perineal membrane on either side of the vagina. Their medial margin is close to the attachment of the puborectalis to the lateral wall of the vagina. Its posterior arc may have been regarded as a ‘pubovaginalis’. It is not part of the urethral sphincter mechanism. Anteriorly, within the subcutaneous tissue of the vestibule may be found fibres of the bulbospongiosus muscle which is often deficient in the midline and therefore not identified in a median episiotomy. It is a weak introital sphincter but the fibres may sometimes be found in the pedicle of fat developed for the Martius operation (see Chapter 21).

Ve ins a nd Lym pha tic s The posterior part of the pelvis and the area above the pelvic rim and sacral promontory are of supreme surgical importance for here is the divergence of the main arterial supply to lower part of the body and the confluence of its venous drainage. Some understanding of vascular embryology is helpful in appreciating the asymmetry of paired vessels and possible variants. The dorsal aorta is developmentally a paired vessel but only the left arch persists. The definitive abdominal aorta tends to occupy a rather more central position than does the inferior vena cava. The common iliac arteries are paired segmental arteries, the terminal dorsal aorta being represented by the small median sacral artery, a small vessel which is nevertheless capable of giving rise to haemorrhage in retroperitoneal surgery for carcinoma of the ovary or for presacral neurectomy.

Bulbospongiosus

Superficial transversus perinei External sphincter ani

Fig. 2.15: Superłcial perineal pouch and muscles, seen from below. Fat has been removed from the ischiorectal fossa to show the paravaginal extension. T2-weighted MR scan of the pelvic Ńoor showing the pubococcygeus and puborectalis muscles.

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Fig. 2.16: Endo-anal ultrasound showing decussation of the superłcial transverse perineal muscle with the external anal sphincter and the deeper part a complete ring (by courtesy of Prof. Clive Bartram).

Surgical Anatomy

VESSELS O F THE LO WER LIMB ARTERIES

Internal Iliac Artery

The primitive arterial supply to the lower limb (ischiadic artery) followed the sciatic nerve out of the pelvis through the greater sciatic notch. This artery arose from the posterior division of the internal iliac artery and is represented in human anatomy by the gluteal vessels which still participate in the cruciate anastomosis with the deep femoral artery in the thigh. The arrangement of perforating arteries from the deep femoral artery to the gracilis muscle remains of importance in reconstructive gynaecological surgery allowing mobility to musculocutaneous grafts from the inner aspect of the thigh (see Chapter 21). Injury to the gluteal artery can occur during transvaginal sacrospinous fixation (see Chapter 14).

The internal iliac artery has two divisions (Fig. 2.17). The posterior division has an association with the roots of the sciatic nerve as they traverse the greater sciatic notch. Because of the cruciate anastomosis (see Fig. 2.17) retrograde flow from this division to the anterior division is possible after ligation of the stem internal iliac artery close to the bifurcation of the common iliac artery. Embryologically, the anterior division of the internal iliac (umbilical) artery is the artery to the extra-embryonic bladder (allantois). In the adult, therefore, the last patent branch of the anterior division of the internal iliac artery is a main artery to the bladder, namely the superior vesical. During radical hysterectomy the obliterated hypogastric arteries (lateral umbilical ligaments) may be identified in the para-vesical space and, if put on the stretch, provide a convenient anatomical guide to the surgeon to the anterior division of the internal iliac artery and hence to the origin of the uterine artery. There is some variation in the origin of these arteries, varying from close to the superior vesical with a short transverse course to the lateral fornix, to a high ‘take off ’ from the formation of the anterior division with an oblique course across the cardinal ligaments to the same site. There is similar variability in the site of origin of the other branches of the internal iliac artery, although the course and distribution tend to be constant.

ILIAC ARTERY The development of the anterior compartment of the thigh resulted in the predominance of the external iliac artery and femoral artery as the main supply to the lower limb. There are no parietal branches of the external iliac artery until it reaches the inguinal ligament. Just occasionally, an anomalous origin of the obturator artery may course over the pubic ramus to the obturator foramen and be at risk in femoral hernia repair and pelvic lymphadenectomy.

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Internal iliac A Anterior division External iliac A Ureter

Obliterated umbilical A Middle rectal A Superior vesical A Cervix Vagina

Pudendal A Anal canal

Uterine A

Fig. 2.17: Internal iliac artery and its relations. Diagonal section of the female pelvis passing from the hip joint to the anal canal. On the left the fat of the para-vesical space and part of the transverse cervical (cardinal) ligament have been removed. Unlabelled are the gluteal, and lateral and median sacral arteries.

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The pudendal vessels accompany the pudendal nerve where they enter the pudendal sheath on the medial aspect of the ischial tuberosity (Alcocks canal). The relationship to the ischial spine is relatively constant. Not only is this important for the insertion of pudendal block for minor surgical and obstetric procedures, but also during the insertion of suspensory sutures in the operation of sacrospinous vaginal fixation placement of a suture close to the tip of the spine runs the risk of vascular and nerve damage (see Chapter 14).

VEINS The veins of the pelvis constitute a veritable ‘mine field’ for the surgeon. Their embryology is obscure and their anatomy characterised by inconstancy even between two sides of the body. The vessels are thin walled and generally without valves, so that haemorrhage from trauma to a major vein will ‘well up’ from two or even three directions.

Inferior Vena Cava Formed from the confluence of the two common iliac veins, the inferior vena cava is essentially a right-sided structure of complex embryology. During embryonic life, there are three pairs of longitudinal veins, the counterparts of the dorsal aorta. These are the cardinal, supracardinal and subcardinal veins. The definitive vena cava is made up of segments of all these vessels with anastomotic channels. It is atypical persistence of a sub-cardinal section which gives rise to the rare retrocaval ureter. The azygos and lumbar veins are important tributaries which need to be respected during lumbar (para-aortic) lymphadenectomy.

ILIAC VEINS

Common Iliac Veins There is marked asymmetry in the course of these vessels, the proximal part of the left common iliac vein being represented embryologically by an inter-cardinal anastomosis. The left common iliac vein is thus substantially longer than its right counterpart and does not have the same proximity to the left common iliac artery. This vein is the lowest major vascular structure in the midline above the sacral promontory. It is, therefore, peculiarly vulnerable to injury during blind insertion of instruments for laparoscopy, either the Veress needle or the trocar.

External Iliac Veins The external iliac veins commence at the inguinal ligament and become the common iliac veins after junction with up to three internal iliac veins. Although it is possible to dislocate medially the external iliac vein from the side wall of the pelvis in order to gain access to the lymph nodes lateral and posterior to the vein, the posterior inferior aspect needs to be treated with great circumspection as large thin-walled vessels may drain directly into the external iliac vein, particularly if the lymph nodes are pathologically enlarged. There is an especially dangerous 24

triangle at the confluence of the main internal iliac vein with the external iliac to form the common iliac. There is a flange of vein wall between the two afferent vessels which is easily torn during pelvic lymphadenectomy. It is most important that fat-containing lymph nodes be drawn downwards and forwards parallel to the external iliac vein rather than lifted upwards. Haemorrhage in this area can only be stemmed by pressure over all three major veins forming the junction. The femoral vein is an important structure within the field of inguinal lymphadenectomy. Within the femoral sheath, the femoral artery is ‘sandwiched’ between the femoral vein and the femoral nerve. Pulsation of the arteries, therefore, is a guide to the position of the vein when venous access for blood sampling is required. The long saphenous vein enters the femoral vein through the saphenous opening and cribriform fascia. There are three or more small veins entering at this site corresponding to the small named arteries which have arisen from the adjacent femoral artery. The long saphenous vein itself lies deep to the membranous layer of the superficial fascia. If traction is applied to the sapheno-femoral junction during mobilisation, tenting of the femoral vein can occur, resulting in its partial obstruction by the ligature.

Internal Iliac Veins The internal iliac veins are deserving of the greatest surgical respect. Haemorrhage from them can be life threatening and testing; the pelvis fills rapidly with dark blood which can usually be staunched by pressure but with rapid resumption of the bleeding when pressure is released. These veins are connected without valves to those from the gluteal region which pass between the roots of the sacral plexus, between which they are prone to retract. Attempts at haemostatic suture in this area carry a significant risk of major nerve root damage. The uterine veins are varied and run a quite different course to the uterine artery. Whereas the latter runs a more or less oblique course from the side wall of the pelvis (anterior division of internal iliac artery) over the ureter to the lateral fornix and supravaginal cervix, the former commonly run inferior to the ureter (although one branch may pass above with the artery). When the ureter is drawn upwards during the operation of hysterectomy the venous drainage is then almost vertically downwards in to the iliac veins. The pre-sacral area, bounded by the left common iliac vein above and the two internal iliac arteries on either side, contains the venous drainage from the buttocks through the gluteal veins. The venous drainage of the sacrum and sacral canal is largely posterior to the pre-sacral fascia (Waldeyer’s fascia). These veins, when torn, can retract into small bony apertures and continue to produce life-threatening haemorrhage. Special haemostatic techniques such as ‘thumb tacks’ or wax may be required.

O VARIAN VEINS Unlike the ovarian arteries, which arise symmetrically from the aorta just below the origin of the renal arteries, ovarian

Surgical Anatomy venous drainage is asymmetrical. The tortuous ovarian veins, often with anastomotic channels across the broad ligament to the internal iliac system, wend their way in the infundibulopelvic fold across the iliac vessels to the level of the renal vessels. Once again, embryology is pertinent to the difference in anatomy at this level. Like the left common iliac vein, the left renal vein consists in its medial portion of an inter-subcardinal anastomosis, which therefore passes anterior to the aorta. The left ovarian vein joins this vessel, the left cardinal system having disappeared. Renal carcinoma invading the renal vein on the left side can sometimes give rise to retrograde venous spread to the female genital tract where secondary tumour in the ovary may histologically resemble primary ‘clear cell’ carcinoma. Because of the broad ligament anastomosis metastatic deposits may find their way through the uterine and vaginal venous system to the ‘water shed’ at the lower quarter of the vagina where external venous drainage to the pudendal system commences. Presumably there is an element of stasis in this region as it is a site of predilection for secondary deposits from the uterus (including choriocarcinoma), particularly in the sub-urethral region.

VASC ULAR SUPPLY O F THE BO WEL Knowledge of the blood supply to the alimentary canal is directly relevant to certain areas of specialist gynaecology. The distribution of vessels and, equally important, the disposition of bloodless planes has an embryological basis. With the disappearance of the yolk sac and closure of the extra-embryonic coelom the intestine undergoes an anti-clockwise rotation about the origin of the superior mesenteric artery. The duodenum becomes plastered against the posterior abdominal wall and at the duodeno-jejunal flexure the small bowel and its mesentery appear from the hub of this rotation. The root of the mesentery which passes down to the right iliac fossa contains the ileo-colic and right colic vessels supplying the terminal ileum, caecum and right colon. This means that lateral and posterior to the caecum and right colon is a bloodless plane where the primitive colonic mesentery adhered (by zygosis) to the posterior abdominal wall. This plane is utilised when the right colon is mobilised and swung medially to expose the vena cava and aorta for the purposes of lumbar (para-aortic) lymphadenectomy (see Chapter 16). The distribution of the blood supply is also relevant to utilisation of the caecum and right colon as an artificial vagina.

Marginal Artery (of Drummond) There is an anastomotic branch between the fields supplied by the right colic, middle colic and left colic arteries. Anastomosis is not as free as between the arcades of the ileum and identification and preservation of this artery is of importance when mobilising the left colon up to the region of the splenic flexure for low anastomosis. At a high level the inferior mesenteric vein and artery are quite separate, the vein occupying one of the para-duodenal folds on its way to form the hepatic portal vein.

The superior haemorrhoidal vessels cross the pelvic brim to the left of the midline. When there is haemorrhage in the area, they can be mistaken for the trunk of the internal iliac artery. Within the pelvis the superior haemorrhoidal vessels are the main supply of the upper rectum. Beneath the peritoneal reflection may be found on either side the middle rectal arteries within the lateral ligaments of the rectum. These do not seem crucial to the viability of the distal stump; with low anterior rectal resection, both lateral ligaments may be divided during mobilisation to the anorectal ring. Distally, there will be an anastomosis with the inferior haemorrhoidal vessels which arch across the ischiorectal fossa from the pudendal vessels to supply the anal canal. On the venous side this is also recognised as an area of portal systemic anastomosis. Above the rectosigmoid junction the blood supply of distal sigmoid colon is from above; viability may be impaired if this is compromised.

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BLO O D SUPPLY O F THE URINARY BLADDER, URETER, VULVA AND ING UINAL REG IO N

Bladder Although the superior vesical artery remains as the last patent branch of the allantoic (umbilical artery) it is not in fact the main blood supply to the adult bladder, which also arises from the internal iliac system as the inferior vesical artery, a large vessel in the male, partly replaced by the vaginal artery in the female. The bladder wall is extremely well vascularised to the extent that bleeding is often the first warning sign to the surgeon of encroachment upon this structure. The vascular pedicle is important when constructing the base of tube grafts for ureteric re-anastomosis (Boari operation, see Chapter 21). The ureter, by way of contrast, has a very tenuous blood supply, being picked up as small branches from most of the neighbouring large arteries, particularly where it crosses the common iliac artery at the pelvic brim. There are further branches from the uterine artery in the ureteric canal; these, of course, will be lost with lateral ligation of the uterine artery during radical hysterectomy. There is a fine mesentery attached to the ureter which lies against the peritoneum on the side wall of the pelvis. This ‘envelope’ should be disturbed as little as possible in radical pelvic surgery as excessive stripping can devitalise the ureter and lead to sloughing and fistula formation.

Vulva and Groin The vulva and its appendages are liberally supplied with blood vessels from the internal and external pudendal systems. The terminal branches of the internal pudendal artery, after giving off the inferior haemorrhoidal artery are the perineal branch and the artery to the clitoris. There is a free anastomosis in the subcutaneous area which means that pedicle grafts of fat are viable whether hinged anteriorly or posteriorly (Martius operation, see Chapter 21). In the inguinal region, the situation is quite different. There are three small arteries given off from the origin of the

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Section A | Introduction, Anatomy, Pre-op. Diagnosis and Management, Imaging, Skill Learning, Postop. Care femoral artery before it gives off its deep (profunda) branch. That which supplies the skin of the groin must be an end artery as sloughing of the skin over the femoral triangle is fairly common after inguinal lymphadenectomy in which these arteries are ligated.

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Lym pha tic Syste m All lymphatic channels from the lower half of the body eventually converge on the thoracic duct after passing 26 through a number of lymph node stations en route. This is the basis for left-sided supraclavicular none involvement in some cases of ovarian malignancy (cp gastric cancer).

LYMPH DRAINAG E O F THE EXTERNAL G ENITALIA

Inguinal Lymph Nodes The lymphatic drainage of the lower limb converges on the medial aspect of the thigh. The primary lymph nodes lie distal to the inguinal ligament and, in modern terminology, are all called inguinal. There is one distal lymph node station in the popliteal fossa. The inguinal lymph nodes are situated superficial and deep to the deep fascia. The superficial inguinal nodes are arranged in a ‘tilted T’ shape with medial and lateral horizontal groups and a vertical chain related to the long saphenous vein before it passes through the cribriform fascia. The medial horizontal group is most likely to be involved in vulval malignancy. The distribution of the lymphatic channels and their relationship to the labio-crural folds were described in a classic exposition by Parry-Jones.15 The deep inguinal nodes (at one time called femoral) are up to three in number in the deep part of the cribriforms fascia just above and below the sapheno-femoral venous junction and also in the femoral canal (Cloquet’s node); the latter is inconstant. Deep nodes are not found distal to this point, but the distal limit of the cribriform fascia may be indistinct. Not all lymphatics from the thigh pass through the femoral canal, but may be seen on lymphography entering the pelvis across the length of the inguinal ligament.

node chains are related to the artery and to the cleft between the vein and artery. Internal iliac nodes are situated between the corresponding artery and vein and posterior to the vein. Lymph drainage from the posterior thigh follows the gluteal vessels to these nodes. Sacral nodes. Lateral and medial groups (the medial are related to the median sacral artery). Common iliac nodes. These have similar distribution to the external iliac nodes. Lumbar nodes (commonly called ‘para-aortic’ although the majority are ‘para-caval’). There are four lymph chains, two lateral and one in front of and one behind the great vessels. Lymph drainage from the ovary is bi-directional with a direct channel to nodes at the level of the renal vessels as well as to nodes on the side wall of pelvis. The uterine fundus may drain in a similar manner, and intraperitoneal malignancy near the deep inguinal ring may involve inconstant, inferior epigastric nodes or the superficial inguinal groups. Another inconstant parietal node is found in the obturator foramen, not to be confused with the inter-iliac group (see the text above). This drains the medial thigh.

Visceral Nodes These relate to the viscera and are labelled parametrial, paravesical and para-rectal. One parametrial lymph node lies between the ureter and uterine artery. The pararectal nodes are the most distal station of the inferior mesenteric group. The lymph node drainage of the cervix is illustrated in Fig. 2.18.

Pelvic Lymph Nodes Although the pelvic nodes are largely located near major vessels, their afferent drainage in no way corresponds those located near the external iliac vessels being first station nodes for some pelvic viscera. Pelvic nodes are parietal and visceral.16

Parietal Nodes External iliac nodes. There are three channels and three node chains on each side. Inter-iliac nodes (commonly but incorrectly called ‘obturator’) are the posterior external iliac group. They lie anterior and superior to the obturator nerve (dissection of the fat beneath this nerve is unrewarding). The other 26

Fig. 2.18: The regional lymph node station of the uterine cervix. Channels 8, 9 and 10 (indicated by especially heavy lines) lead to those regional node stations most frequently reached by the efferent lymph vessels of the cervix. Nonetheless, it is necessary to remember that carcinoma cells can also reach the pelvic lymph nodes by way of channels, 1–7, without previous interruption. To (1) rectal, (2) subaortic (promontorial), (3) aortic, (4) medial common iliac, (5) lateral common iliac, (6) lateral external iliac, (7) sacral, (8) superior gluteal, (9) interiliac and (10) inferior gluteal lymph nodes.

Surgical Anatomy

Ne rve s

perineal nerve is an important anterior branch, and increased transmission latency may result from neuropraxia.

The pelvic contents are visceral and hence the nerve supply, both sensory and motor, is autonomic. Certain somatic nerves, however, pass through the field and the pelvic surgeon needs to be aware of their presence and of their significance.

Auto no mic Ne rvo us Syste m (Fig . 2.19)

FEMO RAL NERVE The lumbar plexus within the false pelvis is well protected from injury until it forms the femoral nerve in the most lateral compartment of the femoral sheath. The femoral nerve should not be exposed in the operation of inguinal lymphadenectomy. It can, however, be injured by abdominal wound retraction. The obturator nerve appears in the pelvis from behind the bifurcation of the common iliac vessel but traverses the ovarian or obturator fossa, disappearing from view through the obturator foramen whence it is responsible for innervation of the medial compartment of the thigh. The nerve is an important landmark during pelvic lymphadenectomy and forms the posterior margin of the dissection field. Involvement of the obturator nerve in this area can give referred pain the medial side of the knee. Likewise severance will produce some analgesia in this area and interference with adduction of the thigh. Walking can be affected.

SYMPATHETIC NERVES On each sympathetic chain every spinal nerve has a ganglion related to the anterior root terminating with the ganglion impar

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SC IATIC NERVE This is formed from the anterior roots of the sacral outflow and the lumbosacral trunk from L5 which crosses the pelvic brim and is susceptible to injury at this point. The nerve roots are protected by a dense fascia. Sciatic pain from malignant infiltration of the area is a sure indicator of inoperability. There is the potential for injury from a misplaced suspensory suture.

G ENITO - FEMO RAL NERVE This supplies a sensory distribution to part of the vulva and adjacent high. It is demonstrable on the surface of the psoas muscle and marks the lateral limit of the dissections required for external iliac lymphadenectomy.

ILIO - ING UINAL NERVE This nerve supplies a slightly higher area of the groin and actually traverses the inguinal canal. Its importance in gynaecology is the risk of entrapment in Pfannenstiel incisions and more particularly within the sutures used for suspensory procedures of the uterus (modified ventrisuspension) or of para-urethral tissues (slings or cystoscopically directed needle suspensions).

PUDENDAL NERVE This accompanies the pudendal vessels in the route described above. Its main branch is the inferior haemorrhoidal, which is important as it is the nerve supply to the external anal sphincter. The nerves enter the sphincter from the posterolateral aspect, a relationship which is relevant to sphincter repair operations. The

Fig. 2.19: The autonomic nerves in the pelvis. Post-ganglionic sympathetic łbres from the thoracolumbar outŃow form the hypogastric plexuses. They are joined by the pre-ganglionic parasympathetic nerves from the sacral nerves 2, 3 and 4. The motor nerve supply to the detrusor muscle of the bladder traverses the root of the cardinal ligament and the parasympathetic innervation of the distal colon and rectum leaves the pelvis retrograde (nerve of Learmonth).

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in front of the coccyx. The preganglionic sympathetic outflow is confined to the thoracolumbar region with grey rami communicantes conveying sympathetic motor fibres which pass up and down the sympathetic chain to relay in the ganglia. White rami leave the ganglia and come together to form the splanchnic nerves. Many sympathetic nerves are closely related to arteries entering the pelvis including the iliac and ovarian arteries. Some of the sympathetic motor supply to pelvic organs from lower thoracic roots forms the superior hypogastric plexus in front of the sacral promontory below the left common iliac vein. This plexus also transmits visceral afferent fibres from those areas innervated by thoracic segments (e.g. cervix and uterus). The distribution of sensory fibres is variable but interruption of the hypogastric plexus (pre-sacral neurectomy) can reduce upper genital sensitivity and in particular abolish the pain of uterine contractions. In the female, there is little motor change following a pre-sacral sympathetic nerve resection, most of the efferents being associated with vascular tone. In the male, however, erectile dysfunction can result from their interruption.

PARA- SYMPATHETIC NERVES The pelvic para-sympathetic outflow is provided by the pelvic splanchnic nerves related to sacral segments S2, 3 and 4. These form the inferior hypogastric plexuses either side of the ampulla of the rectum joining in with some of the efferents from the superior hypogastric plexus and also further postganglionic sympathetic fibres from the ganglia associated with the sacral nerves. This is the reason why the pre-sacral neurectomy procedure does not have demonstrable effect upon either the para-sympathetic or sympathetic innervation of the bladder. These pelvic splanchnic nerves course forwards on the side walls of the pelvis to reach the trigone and base of the bladder (nervi erigentes). Inevitably they have to pass through the lateral attachments of the transverse cervical (cardinal) ligaments. This will be in the outer third of these ligaments, but the actual situation is variable. It means that there is in some cases a substantial risk of denervation of the bladder by wide resection of the cardinal ligaments at radical hysterectomy (see Chapter 16).

Bo ny Pe lvis The anatomy of the female bony pelvis has long been of relevance to the obstetrician. However, with an increase in interest the application of surgery to problems in the posterior compartment of the pelvis, bony land marks in the area become important, not only for interpretation of images but also as tactile points of reference. Perhaps the most important of these are the ischial spines. 28

C o nc lusio n Anatomy is a living science and individual to each person. The principles of applied anatomy and associated physiology outlined in this chapter are essential for the understanding of much gynaecological pathology and for the demarcation of appropriate treatment. All the various functions of the pelvis, particularly continence and coitus, need due consideration before surgical interventions are undertaken which can have far reaching effects on subsequent quality of life.

Re fe re nc e s 1. Herbst AL, Ulfelder H, Poskanzer DC. Adenocarcinoma of the vagina. Association of maternal stilbestrol therapy with tumor appearances in young women. N Engl J Med. 1971;284:878–81. 2. Zacharin RF, Hamilton NT. Pulsion enterocele. Obstet Gynecol. 1980;55:141–8. 3. Shaw W. Study of surgical anatomy of the vagina with special reference to vaginal operation. Br Med J. 1947;1:477–82. 4. Geary WL, Weed JC. Congenital atresia of the uterine cervix. Obstet Gynecol. 1973;42:213–7. 5. American Fertility Society. Classiication of adnexal adhesions, distal tubal occlusion, tubal occlusion secondary to tubal ligation, tubal pregnancies, mullerian anomalies and intra-uterine adhesions. Fertil Steril. 1988;49:944–54. 6. Rock JA, Jones HW. he double uterus associated with an obstructed hemivagina and ipsilateral renal agenesis. Am J Obstet Gynecol. 1980;138:339–42. 7. Gosling JA, Dixon JS, Critchley HOD, hompson SA. A comparative study of the human external sphincter and pen-urethral levator ani muscles. Br J Urol. 1981;53:35–41. 8. Stelzner F. Die Anorektalen Fistulen. Berlin: Springer-Verlag; 1981, p. 1–30. 9. Parks AG. Modern concepts of the anatomy of the ano-rectal region. Postgrad Med J. 1958;34:360–6. 10. Richardson AC, Lyon JB, Williams NL. A new look at pelvic relaxation. Am J Obstet Gynecol. 1976;126:568–73. 11. Zacharin RF. he anatomic supports of the female urethra. Obstet Gynecol. 1968;21:754–9. 12. DeLancey JO. Anatomic aspects of vaginal eversion ater hysterectomy. Am J Obstet Gynecol. 1992;166:1717–28. 13. McCarthy S, Vaquero E. Gynecologic anatomy with magnetic resonance imaging. Am J Obstet Gynecol. 1986;155: 255–9. 14. Sultan AH, Nicholls RF, Kamm MA, Hudson CN, Beynon I, Bartram C. Anal endo-sonography and correlation with in-vitro and in-vivo anatomy. Br J Surg. 1992;80:808–11. 15. Parks AG, Swash M, Urich H. Sphincter denervation in ano-rectal incontinence and rectal prolapse. Gut. 1977;18: 656–65. 16. Hudson CN. Lymphatics of the pelvis. In: Philipp E, Setchell ME, eds. Scientiic Foundations of obstetrics and gynaecology. Oxford: Butterworth; 1991, p. 100–110.

Pre - o pe ra tive Asse ssm e nt a nd Dia g no stic Pro c e dure s

3

Marcus E. Setchell

Pre - o p e ra tive A sse ssm e nt a nd Dia g no sis

Table 3.2:

Examples of multidisciplinary clinics

Clinics

Additional specialists

Pelvic Ńoor

Colorectal surgeon Radiologist Anorectal physiologist

Gynaecological cancer

Radiotherapist Medical oncologist Palliative care physician

Fertility

Andrologist Endocrinologist

Pelvic pain

Pain control specialist Psychologist

Vulval disorders

Dermatologist Psychologist

INTRO DUC TIO N The pattern of specialist care of patients requiring surgery has changed radically over the last two decades, and this has been particularly evident in gynaecology. Although all medical students have traditionally received some teaching in gynaecology, it is only more recently that general practitioners (GP) and nurses have taken on a wider role in the provision of services in areas such as contraception, cervical screening and the preliminary investigation and management of many gynaecological conditions. Often the GP works closely with hospital specialists, using jointly developed and agreed protocols of management. Where these are well developed the GP can not only book patients directly into a specialist clinic, but in some situations book them directly on to the Consultant’s operative waiting list. Rather than traditional general gynaecology clinics, many hospitals now have subspeciality clinics for disease or symptomcomplex disorders. Some of these run as multidisciplinary clinics with nurse-specialists, counsellors, consultants from other specialities and ultrasound scanning or other diagnostic facilities available (see Tables 3.1 and 3.2).

SPEC IALIST C LINIC An increasingly popular concept is to provide a ‘one-stop’ clinic, where all diagnostic services relevant to the particular specialist clinic, whether it be ultrasound scanning, blood tests, immediate radiological referral, colposcopy and biopsy, out-patient hysteroscopy, etc. are available for the patient attending the clinic on the first appointment. Table 3.1:

Examples of specialty out-patient clinics as used in many hospitals

Childhood & adolescent

Pelvic pain

Colposcopy

Pre-admission

Early pregnancy diagnostic

Rapid access

Fertility

Reproductive medicine

Fibroids/endometriosis

Recurrent miscarriage

Gynaecological cancer

Termination of pregnancy

Menopause

Urogynaecology & pelvic Ńoor

Menstrual disorders

Vulval disorders

A clinical history proforma is often completed by the general practitioner prior to the first appointment, or by a clinical nurse practitioner at the clinic. Depending on the nature of the specialist clinic, preliminary pathological investigations may have been done before the first visit to the clinic. Other basic investigations, such as an ultrasound scan may be done before the patient is seen by the Consultant, who then takes a clinical history, based on the proforma if one has been completed, expanding on relevant points, before carrying out a clinical examination. This is likely to include as a minimum an abdominal and vaginal examination, and where appropriate a more general medical and/or rectal examination, with attention to any other relevant system. A preliminary diagnosis may be able to be made, decisions taken regarding the need for any other investigations, and a plan of clinical management explained to the patient and her partner or any other relative or friend if she so chooses. If more complex imaging or pathology tests are needed, a second visit will be necessary before reaching a definitive management plan. In some hospitals, the patient can be booked for a day case or in-patient admission straightaway, and all the pre-admission arrangements, including the consent form, pre-anaesthetic and medical checks are done straightaway, whilst others prefer an additional pre-admission clinic visit a week or two prior to the day of operation. This kind of ‘Clinical Care Pathway’ is intended to streamline the process for the patient, and make economically efficient use of resources. The patient, however, may find this a bewildering and de-humanising experience

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during which she has been seen by a large number of different members of the clinical team and left with an impression of being ‘processed’ without a clear understanding of what is happening. It is extremely important for all members of the team to introduce themselves, explaining their role and giving the patient plenty of time to ask questions and have them answered. Whilst the use of hand-out literature may be a useful adjunct, it must never be allowed to replace doctor/nurse communication with the patient.

PRE- ADMISSIO N C LINIC Most of the preparatory tasks that used to be undertaken after admission to hospital now take place in the pre-admission clinic sometime before admission, as explained above. This pre-operative check includes a review of any relevant medical, anaesthetic, drug and allergy history, and confirmation of the diagnosis and operative procedure to be carried out, leading to the production of documentation usually on a standard template proforma. If a medical condition requires review appropriate referral can be made and pre-operative blood and urine checks done, as well as an ECG, chest X-ray and any other simple investigations. Ideally, an anaesthetist should be present or available in the clinic. The exact nature of the operation will be explained to the patient, and the consent form may be completed. The pre-admission clinic will have ensured that the patient clearly understands the duration of pre-operative abstinence from food and drinks, smoking, medication withdrawal and any other instructions. She should also have been informed about expected length of stay, time off work, likely postoperative recovery and restrictions on activity. She should be advised about making arrangements for collection and transport home. This is especially important for elderly or socially isolated patients, for whom special transport or escort plans may be necessary.

HO SPITAL ADMISSIO N

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Day case patients are usually admitted two hours prior to the starting time of the operating list, and it is now unusual for patients to be admitted for in-patient operations more than a few hours pre-operatively. Exceptions might be a patient requiring a blood transfusion, or needing local skin or sepsis care prior to surgery, e.g. fistula patients. Even bowel preparation is often given to the patient for self-administration at home prior to admission. Shortly after admission, the patient is confronted by another overwhelming array of staff, including receptionist, nurses, junior doctors, anaesthetist and surgeon, to which may be added medical and nursing students, physiotherapist and others. All these staff will be asking questions and giving information, whilst checking documentation, ticking boxes and form-filling to ensure that nothing has been omitted. If the consent form has been completed in the pre-admission clinic it is important to discuss again with the patient in case there have been intervening changes in symptoms, and to confirm that she understands and is comfortable with what is planned. Sometimes there has been such a substantial change in the patient’s

condition that the planned procedure is no longer appropriate, and in such cases there should be no hesitation in cancelling or changing the procedure. Further explanation and reminders about what to expect in the early postoperative recovery phase should be given.

BLO O D TESTS Checking the results of blood tests, and repeating them if necessary, is essential. Almost all patients having gynaecological procedures, even of the most minor nature, should have had the following tests recently, and the results be available: (a) Haemoglobin (and FBC if anaemia is suspected because of menorrhagia or clinical appearance). (b) Haemoglobinopathy screening where clinically indicated. (c) Blood group, because of the rare possible risk of haemorrhage in even the most minor operations such as termination of pregnancy or laparoscopy. It is also important to know the Rhesus group when a patient is in early pregnancy, so that Anti-D prophylaxis can be given if required. (d) Hepatitis B screening is mandatory in many hospitals for all operative patients, and HIV screening is advisable for selected high-risk groups. (e) Beta HCG pregnancy test should be carried out in women of reproductive age who are in the second half of their menstrual cycle or the menstrual period is late. This is particularly important if the patient is having a sterilisation or intervention for infertility. (f) Routine urine dip-stick testing for protein and glucose.

THRO MBO PRO PHYLAXIS All patients should be risk assessed for thromboembolism, taking into account any previous history of thrombosis, family history, and risk factors (such as age, obesity, smoking, immobility) and the nature of the surgery.1,2 This assessment may have been made in the pre-admission clinic. Risk is assessed as low, medium and high, using a guideline, such as those issued by the RCOG, NICE, or local modification thereof (see Table 3.3),3 and a decision is made and documented as to whether simple measures, such as TED stockings are to be used, or low-dose heparin prophylaxis.

O THER C O NSIDERATIO NS Policies regarding skin shaving and marking vary in different hospitals. Hair clipping will often suffice to avoid hair getting into the operative field or obscuring the surgeon’s view, and shaving should be kept to as small an area as necessary. Skin marking procedures designed to prevent wrong site, side or operation are increasingly used, and have been shown to reduce of rare but serious errors. Last minute changes to operating list order are another potential source of mistakes; information, both written and verbal, must be given to ward staff, anaesthetist, and theatre staff about any such changes. Pre-med sedatives and analgesics are now rarely given, and finally the patient is ready to go to theatre. Provided she is

Pre-operative Assessment and Diagnostic Procedures Table 3.3A:

Assessing risks of venous thromboembolism (VTE) and bleeding

VTE risk factors

Patients who are at risk of bleeding

• • • • • • •

All patients who have any of the following: • Active bleeding • Acquired bleeding disorders (such as acute liver failure) • Concurrent use of anticoagulants known to increase the risk of bleeding (such as warfarin with INR >2) • Lumbar puncture/epidural/spinal anaesthesia within the previous 4 hours or expected within the next 12 hours • Acute stroke • Thrombocytopaenia (platelets 60 years Critical care admission Dehydration Known thrombophilias Obesity (BMI >30 kg/m2) One or more signiłcant medical comorbidities (for example, heart disease; metabolic, endocrine or respiratory pathologies; acute infectious diseases; inŃammatory conditions) Personal history or łrst-degree relative with a history of VTE Use of HRT Use of oestrogen-containing contraceptive therapy Varicose veins with phlebitis

Table 3.3B: Balancing the risks of VTE and bleeding before offering VTE prophylaxis If VTE risk increased • Offer mechanical VTE prophylaxis at admission* • Continue until mobility no longer signiłcantly reduced If risk of major bleeding low • Add low molecular weight heparin (LMWH) • Continue until mobility no longer signiłcantly reduced (generally 5–7 days) Major cancer surgery in the abdomen or pelvis • Continue pharmacological VTE prophylaxis for 28 days after surgery. *Choose any one of the following: • Anti-embolism stockings (thigh or knee length) • Foot impulse devices • Intermittent pneumatic compression devices (thigh or knee length)

reasonably fit and mobile, most patients now walk to the anaesthetic room, rather than be wheeled on a trolley. Once in the anaesthetic room, further checks are done to ensure that the correct patient has arrived for the expected operation.

EMERG ENC Y ADMISSIO N Emergency Admission to hospital still accounts for an appreciable volume of the gynaecological workload of most large hospitals, but patients no longer all arrive via the Accident and Emergency Department, because of the development of Early Pregnancy Diagnostic (or assessment) Units and various forms of Emergency Gynaecology Clinics which cater for same-day referrals from general practitioners or patient self-referral. The geographical siting of these clinics will vary in different hospitals, perhaps adjacent to other Gynaecology Clinics or wards, or the A&E Department. Substantial vaginal bleeding (whether due to a miscarriage or exceptionally heavy menstrual bleeding) and acute lower abdominal pain from conditions such as ectopic pregnancy, ovarian cyst accidents and pelvic inflammatory disease are just some of the more common conditions that may still present through the A&E Department at any time (see Table 3.4). Emergency patients are often initially assessed by

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Table 3.4: Common causes of emergency gynaecological admission Spontaneous miscarriage (Incomplete/inevitable) Ectopic pregnancy Acute pelvic infection Tubo-ovarian abscess Ovarian cyst torsion/rupture Severe menorrhagia Bartholin’s abscess Urinary retention Postoperative complications

relatively junior staff, but 24 hour availability of ultrasound scanning machines, rapid pregnancy testing and haematological investigations allows a diagnosis to be made in A&E or the Emergency Clinic prior to admission to the emergency gynaecological ward, and in some cases the patient may return home for operation the following day, whether as a day case or in-patient. Similar documentation is prepared for emergency admission patients. Many hospitals have one or more consultants with a designated lead position as lead clinician(s) for this emerging speciality. This welcome change is to improve the care of emergency patients, who in the past were not regarded as high priority and did not always get the best and most prompt attention.

Dia g no stic Pro c e dure s HYSTERO SC O PY

Introduction The advantage of directly inspecting the uterine cavity rather than performing blind biopsy and curettage began to appeal to gynaecologists in the early 1900s,4 and attempts were made to examine the uterine cavity with a modified cystoscope. The technical difficulties of uterine distension and poor illumination prevented the procedure becoming useful until the arrival

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of fibre optical hysteroscopes in the 1970s. Initially, the use of diagnostic and operative hysteroscopy remained the preserve of a few enthusiasts, but by the 1980s the equipment had reached a point of development whereby hysteroscopy could be carried out simply and relatively cheaply in a day surgery unit. The advent of smaller guage scopes has led to a growing practice of out-patient hysteroscopy without anaesthesia, although local anaesthesia may be used if the cervical os is tight. The operation of dilatation and curettage (D&C, see Chapter 7) was long regarded as the standard method of investigating and treating intra-uterine pathology, (even if its critics, labelling it ‘an operation for the diagnostically destitute’, deplored its overuse). Today it has virtually been replaced as a diagnostic procedure by hysteroscopy and directed biopsy, and as a therapeutic operation by electrosurgical resection, snaring and laser techniques for observed pathology. A diagnostic hysteroscope consists of an outer sheath through which a distending medium is passed under pressure. Normal saline is by far the most widely used medium, but carbon dioxide is still used by some clinicians, who find it less messy. The telescope, consisting of a lens system and fibre optic illumination bundles, couples tightly to the sheath to prevent leakage of distending medium. For out-patient hysteroscopy, a 3 mm telescope with a 4 mm outer sheath is recommended, whilst for theatre usage a larger 4 mm telescope with a 5.5 mm sheath is more generally used (Fig. 3.1). Flexible hysteroscopes are much more expensive, difficult to sterilise and offer few advantages. The use of a video camera attached to the eye piece allows magnification, a more comfortable operating position, and demonstration of the intra-uterine findings to trainees and theatre staff, as well as allowing permanent photographic or video images to be made.

Indications The indications for hysteroscopy include abnormal uterine bleeding, such as menorrhagia, intermenstrual bleeding, prolonged menstruation and post-menopausal bleeding. Regular cyclical heavy bleeding in a woman under 40, with a normal size uterus is unlikely to reveal intra-uterine pathology

and should be reserved for those who have failed to respond to medical treatment. Other indications for hysteroscopy include recurrent miscarriages, infertility, suspected congenital abnormalities of the uterus, secondary amenorrhoea and misplaced or lost IUCD. Transvaginal ultrasound is usually done as a screening test and a normal scan may obviate the need for a diagnostic hysteroscopy. Saline sonography may also be helpful to demonstrate intra-uterine filling defects.

Technique The patient is placed in the lithotomy position, the vagina and cervix are cleaned with an aqueous antiseptic solution and the position of the uterus confirmed by bimanual examination. A Sims’ speculum is inserted and a tenaculum or vulsellum forceps applied to the anterior lip of the cervix. A uterine sound is passed to confirm the axis of the uterus. The hysteroscope is then connected to the distension medium and the cervix dilated by hydrodilatation pressure under direct vision. If the cervix is stenosed it may be necessary to gently dilate it to 3–4 mm, ensuring that the dilator is only passed just through the internal os. If a low-viscosity fluid is used, normal saline or dextrose 5% are perfectly adequate for diagnostic purposes. To provide adequate uterine distension, the intra-uterine pressure needs to be 40–50 mmHg, and this may be achieved by hydrostatic pressure whereby the bag of infusion fluid is kept 1 metre above the patient, or by the use of a pressure cuff around the infusion bag. More sophisticated pressure rotatory pumps are available and are particularly useful for therapeutic procedures, such as endometrial resection or resection of fibroids, where continuous flow of fluid is necessary. If CO2 is being used, a CO2 insufflator which delivers gas at a maximum rate of 100 mL/min is used (Fig. 3.2). The author prefers the use of a simple pressure cuff on a bag of normal saline for diagnostic hysteroscopy, both in out-patients and the theatre, but concedes that CO2 may be less messy. Once the hysteroscope is passed under direct visual control through the cervix, it may take a few moments for the whole uterine cavity and fundus to become well distended. Each

o i

RB CO H 2 YSTE

Fig. 3.1: A variety of hysteroscopes in common usage.

32

o i

ROFLA TOR

Fig. 3.2: CO2 hysteroŃator.

Pre-operative Assessment and Diagnostic Procedures uterine cornu is identified, and the cavity carefully inspected for pathological lesions; it is desirable to take still photographs from the video camera system to provide permanent documentation (see Figs. 3.3–3.5). If a directed biopsy is to be taken, the hysteroscope must be withdrawn and a wider sheath with operating channel used. In the anaesthetised patient a full D&C may be performed if there is generalised hyperplastic endometrium, or a directed biopsy or polypectomy may be performed. Major interventions such as myomectomy, endometrial resection and division of a septum

or adhesions should only be carried out after full discussion with the patient (see Chapter 9).

Out-Patient Hysteroscopy Increasingly, straightforward hysteroscopy is being carried out as an out-patient procedure without anaesthesia, or with a paracervical block and mild sedation or analgesia.5 It has been shown to be acceptable to many women and to have a failure rate virtually no higher than when done with anaesthesia. However studies have shown that between 3% and 10% of women report severe pain and would not recommend it to their friends.6,7 The technique is essentially the same as any diagnostic hysteroscopy, but narrower guage instruments are used and avoidance of dilatation of the cervix is particularly important as this is likely to cause pain and/or vaso-vagal shock. It has proved less popular for therapeutic hysteroscopy, other than for the simplest of procedures (e.g. polypectomy) because of the narrow working channel and unpredictability of patient tolerance.

3

Complications

Fig. 3.3: Hysteroscopic view of normal tubal ostium.

Fig. 3.4: Hysteroscopic view of polypoidal endometrium.

Fig. 3.5: Hysteroscopic view of endometrial carcinoma.

The important complications of hysteroscopy include perforation and fluid absorption. Whilst the latter is an important risk in ablation procedures, particularly where glycine or sorbitol are used (see Chapter 9), the use of normal saline in diagnostic hysteroscopy is unlikely to lead to any electrolyte disturbance, even if there is excessive absorption. Nevertheless, the amount of fluid input and an estimate of outflow should be recorded. Perforation will be apparent because of failure to maintain distension and poor visualisation of the cavity. The hysteroscope should be removed and if there is evidence of appreciable bleeding, laparoscopy should be performed and usually the bleeding can be controlled with diathermy or a suture. If there is insufficient evidence of bleeding to warrant immediate laparoscopy, the patient should be observed for a few hours and prophylactic antibiotics given. Infection as a complication of hysteroscopy is rare, but if during the procedure there is suspicion of cervical or pelvic infection, prophylactic antibiotics may be given.

DIAG NO STIC LAPARO SC O PY The establishment of laparoscopy, sometimes known as peritoneoscopy or celioscopy, has been the major advance in diagnostic gynaecology in the latter part of the twentieth century, owing much to the work and writings of Palmer,8 and Steptoe.9 The early techniques of laparoscopy were performed between 1910 and 1940, mainly by physicians. In the 1940s culdoscopy or transvaginal peritoneoscopy via the pouch of Douglas was developed and widely practised in the USA, but this has now been abandoned throughout the world in favour of laparoscopy. Diagnostic speculation can now be replaced by precision and certainty. Nevertheless, it cannot be too strongly emphasised that laparoscopy is a potentially hazardous technique with an appreciable morbidity and even mortality, especially where 33

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operative procedures involving the use of intraperitoneal diathermy are concerned. The wider the application and the readiness with which the procedure is undertaken makes attention to safety ever more important. Both endoscopist and anaesthetist must be aware of the particular complications and the ways of avoiding them. No gynaecologist should attempt laparoscopy unsupervised until he/she has been properly trained in safe technique, avoidance and recognition of problems, and their management should they occur.10

Technique Laparoscopy is carried out in the operating theatre under full aseptic precautions. Local anaesthesia can be employed if conditions are suitable and the patient so motivated. Usually, however, general anaesthesia is preferred, both for patient comfort and predictability of successful completion of the procedure. The particular problems related to a carbon dioxide pneumoperitoneum, such as diaphragmatic splinting, inferior vena caval compression, gastric regurgitation and hypercapnia due to carbon dioxide accumulation leading to possible cardiac arrhythmias, may largely be overcome with a cuffed endotracheal tube, muscle relaxants and positive pressure ventilation.

Procedure The patient is placed in the semi-lithotomy (Lloyd Davies) position as for abdomino-perineal operations. The abdomen, vagina and perineum are cleansed and draped (Fig. 3.6) so that laparoscopy may be abandoned in favour of laparotomy at any stage in the proceedings without re-draping or re-positioning the patient. The bladder is catheterised and bimanual examination performed. If a hysteroscopy is also being undertaken it is appropriate to do it at this stage. If it is not, the cervix may require slight dilatation in order to insert an insufflation cannula (e.g. Spackman cannula or derivative) which is then locked on to the cervix in order that the uterus may be manipulated and dye injected if indicated. This step is omitted if there is any possibility of an intra-uterine pregnancy. The patient is supine until after the insertion of the first trocar and cannula. A small incision, usually vertical (or hori-

Fig. 3.6: Laparoscopy. A patient in position for laparoscopy.

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Fig. 3.7: Laparoscopy. The umbilicus may be held steady with the left hand or with tissue forceps. The Veress needle is inserted at right angles to the skin of the abdominal wall, directly through the umbilicus.

zontal depending on the anatomy of the particular umbilicus and previous scars), is made through or in the inferior aspect of the umbilicus. A Veress needle is tested, and grasping it like a pencil well down the shaft, inserted through the umbilical incision at right angles to the skin, (see Fig. 3.7) until it is felt to have just penetrated the skin. There is virtually no subcutaneous fat in the umbilicus itself, even in moderately obese patients. The needle consists of a spring-loaded blunt perforated trocar within a sharp cannula. Resistance allows the sharp cannula to protrude, and loss of resistance allows the blunt trocar to spring forward again, thus diminishing the risk of perforating a viscus as the peritoneal cavity is entered. Once through the skin, the direction of the needle is continued until a second click is felt or heard as it penetrates the linea alba and peritoneum. Great care must be taken not to advance the needle further into the peritoneal cavity, as the intestine may be very close. (see Fig. 3.8). Before insufflation of carbon dioxide gas, aspiration with a syringe with 10 mL of saline attached to the needle helps to ensure that the tip is not misplaced in a viscus or blood vessel. As a further test, a small volume of saline is injected, and re-aspiration attempted. If the fluid is returned, the needle point is likely to be in a loculus rather than the general cavity. Provided it has not returned a ‘drop’ test may be done to see that saline enters freely under negative pressure. The needle is then connected to the insufflation apparatus [e.g. Semm’s machine (WISAP)] and the gas introduced until the intraperitoneal pressure reaches 20–25 mmHg. If the pressure is unsatisfactory the needle should be re-inserted once, but if this still fails to produce a satisfactory pneumoperitoneum, it should either be re-inserted via Palmer’s point (see below), or the Hassan open technique applied. Adequate distension of the abdomen is usually obtained with 3–5 litres of gas. Studies have shown that if the peritoneal pressure has been raised to 20 mmHg, the volume of gas instilled will mean that there is a distance of 5–7 cm between the skin and any abdominal viscus.

Pre-operative Assessment and Diagnostic Procedures second port to clearly demonstrate all the pelvic viscera. If there is any possibility that some minor operative procedure may need to be done, it is usual to insert the second port, in one or other iliac fossa, after transillumination of the abdominal wall and having visualised the obliterated umbilical arteries. At the end of the operation as much gas as possible is expelled through the cannula by pressure on the abdomen and clips, sutures, or adhesive glue are applied to the puncture wounds.

3

Indications

Fig. 3.8: Laparoscopy. The Veress needle is only advanced until it has just entered the peritoneal cavity, so as to avoid penetration of intestine or aorta.

The insufflation needle is then withdrawn and a larger 5 or 10 mm trocar and cannula (Fig. 3.9) is inserted perpendicular to the skin and then through the abdominal wall with a firm direct push. Once through the peritoneum the trocar is withdrawn and the laparoscope introduced. The pressure is now reduced to 15 mmHg and the gas volume will be satisfactory to maintain good visualisation without splinting the diaphragm and causing ventilatory difficulties once the patient is placed in the Trendelenberg position. Once the laparoscope, with or without a video camera attachment, has been inserted, the patient is placed in a steep Trendelenburg position. In order to manipulate the pelvic contents and to visualise the full length of the Fallopian tubes and all surfaces of the pelvic viscera, it is necessary to introduce a second instrument. If the procedure is purely diagnostic, the second port may be placed centrally about 3 cm above the pubic bone rather than in the iliac fossa, after transilluminating the abdominal wall to avoid puncturing blood vessels. A blunt probe or atraumatic forceps may then be passed through the

The indications for laparoscopy may be considered as diagnostic or therapeutic. In the former category, the laparoscope enables the clinician to make a precise diagnosis in the frequently difficult clinical situations of suspected ectopic pregnancy, pelvic inflammatory disease or endometriosis. Moreover, in most cases of indeterminate pelvic pain a gynaecological cause may be either proven or eliminated. It is important to record and document the findings carefully and most units now have access to good digital photographic or video recording equipment to create permanent images of any pathology. In the investigation of infertility laparoscopy is invaluable. A dye, such as methylene blue, is injected through an intracervical cannula and it may be seen to traverse the tubes and spill from their fimbrial ends. If no dye enters the tube it may be because there is a cornual obstruction, but it may be artifactual either because of a loose fit of the intra-uterine cannula and leak-back of the dye or tubal spasm. If dye enters the tubes its presence may be seen through the serosa so that if the tubes are not patent, the site of the block may be determined. Blockage of the fimbrial end will lead to distension of the tube and a hydrosalpinx will become obvious. In evaluating ovarian function for infertility or menstrual disturbance, a direct inspection of the ovaries enables their size to be assessed, and the presence of follicles, corpora lutea, or polycystic ovaries cysts to be detected. If the patient’s complaint has been pelvic pain or dysmenorrhoea, a careful inspection for endometriosis must be made on the surface of the ovaries and the whole of the pelvic peritoneal surface. The presence of adhesions may also be detected whether this is secondary to endometriosis or pelvic infection. Uterine fibroids and congenital anomalies may be found, and their importance assessed.

Biopsies and Aspiration

Fig. 3.9: Laparoscopy. Insertion of trocar and cannula through umbilical incision.

Biopsy of suspected endometriosis or peritoneal nodules may be taken with scissors or biopsy forceps. Diathermy coagulation to achieve complete haemostasis is used if necessary Aspiration of ascitic fluid or the taking of peritoneal washings may be made if appropriate. If there is pus present in the Pouch of Douglas or a tubo-ovarian abscess the fluid may be aspirated for microbiology testing, and if substantial, a drain inserted. Ovarian cysts or para-ovarian cysts may be aspirated under direct vision and the aspirate sent for cytological examination. If the cyst fluid appears to be from an endometrial or dermoid cyst, it is particularly important to thoroughly wash out and aspirate the peritoneal cavity in order to prevent implantation

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Section A | Introduction, Anatomy, Pre-op. Diagnosis and Management, Imaging, Skill Learning, Postop. Care of endometrioid cells in the former case, and chemical peritonitis in the case of dermoid cysts. The danger of implantation of malignant cells should not be under-estimated and aspiration of a potentially malignant ovarian cyst should only be attempted after careful consideration. Operative laparoscopy is described in appropriate chapters.

Laparoscopic complications and their causes

Table 3.5:

A. Introduction of pneumoperitoneum and instruments • Emphysema • Gas embolism • Haemorrhage • Haematoma

3

Contraindications

• Intestinal perforation

Any pre-existing cardiovascular or respiratory condition that precludes pneumoperitoneum or the Trendelenburg position should be regarded as a contraindication to laparoscopy. Laparoscopy should only be carried out in the presence of generalised peritonitis, intestinal ileus or obstruction by a highly experienced gynaecologist, who understands how and when to use the Hassan open technique or Palmer’s point entry approach (see Fig. 3.10). The presence of adhesions does not preclude laparoscopy, but introducing instruments through, or close to, abdominal scars should be avoided. The production of the pneumoperitoneum may be difficult and the whole procedure should be abandoned if the abdominal cavity is so loculated by adhesions that the intraperitoneal pressure cannot be kept within the safety limits.9

• Respiratory or circulatory embarrassment

Complications (Table 3.5) Whilst some complications are less severe than others – transient shoulder pain due to any residual pneumoperitoneum is an invariable event – the more serious sequels can be life threat-

Palmer's point

• Omental and port site hernia • Aggravation of existing hernia B. Operative instruments including diathermy • Burning of skin and abdominal wall • Burning of intestine • Crushing/scissor injury to intestines • Peritonitis • Haemorrhage – primary or secondary • Pelvic sepsis • Bladder and ureteric injury

ening. Blood vessels or an intra-abdominal viscus may be punctured by the sharp instruments. The introduction of carbon dioxide may be associated with embolism, emphysema and the consequences of hypercapnia leading to respiratory and cardiovascular problems. Infection may result from poor asepsis, exacerbation of pre-existing pelvic inflammation or breach of the gastrointestinal tract. When diathermy is used burns of the abdominal wall can occur, but more significantly intra-abdominal structures, particularly bowel, may be burned leading to necrosis and peritonitis. Often the damage is unrecognised at the time of operation. Hernia of intraperitoneal contents, especially omentum, may occur in relation to puncture sites, particularly if 10 mm or larger ports are used. Suturing of the rectus sheath with a J-needle of large port sites (other than the umbilicus) should be mandatory. Ureteric and bladder damage by diathermy coagulation or puncture have also been reported. The Royal College of Obstetricians and Gynaecologists Confidential Enquiry into laparoscopy and its complications revealed an overall complication rate of 34/1000, of which only 2 per 1000 represented damage to bowel or urinary tract. A mortality rate 0.08/1000 was reported. Although laparoscopy is such a valuable procedure it cannot be too strongly emphasised that the potential hazards are serious. It is mandatory therefore that steps are taken to avoid complications at all times. An adequate training for the intraperitoneal endoscopist is absolutely essential.11

Extra g e nita l Endo sc o py

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Fig. 3.10: Surface markings of Palmer’s point, 2 cm below the left costal margin in the mid-clavicular line. Note the anastomosis between the inferior and superior epigastric vessels. The superior epigastric artery is medial to the incision site.

C YSTO - URETHRO SC O PY (FIG . 3.11) Endoscopic examination of the bladder is of particular relevance to the gynaecological surgeon. Apart from the diagnosis

Pre-operative Assessment and Diagnostic Procedures

However, the gynaecologist will find it useful to gain experience in proctoscopy, both in out-patients and in theatre. Not all gynaecologists will be skilled in the use of the sigmoidoscope, but those whose work includes gynaecological cancer or fistula work would be well advised to acquire the necessary skills. Flexible fibre optic colonoscopy is a highly skilled procedure which should only be carried out by an appropriately trained endoscopic gastroenterologist. Fig. 3.11: Cystoscopy. Operating cystoscope with łbre optic light source.

of intrinsic vesical pathology, he or she should be able to identify the ureteric orifices and catheterise the ureters, if necessary. The relationship of the intramural ureter to a vesical fistula is often important. Urethroscopy is a neglected procedure but is highly relevant to the study of defective control of micturition and urethral bleeding (see Chapter 21). The gynaecologist is advised that operative endoscopy should be left to the urologist, particularly the use of the transurethral resectoscope. The potential for damage in the female with this latter instrument even in relatively skilled hands is considerable.

PRO C TO SIG MO IDO SC O PY AND C O LO NO SC O PY Gynaecologists should be able to perform proctoscopy, in order to identify pathology of the anal canal, which will be particularly useful if there is doubt as to whether bleeding is vaginal or rectal in origin. It is also useful in the identification and localisation of low rectal or anal fistula. Many such cases will require co-operative management with a colo-proctological colleague.

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Re fe re nc e s 1. Robinson GE, Burren T, Mackie IJ, et al. Changes in haemostasis ater stopping the combined contraceptive pill: implications for major surgery. Br Med J. 1991;302:269–71. 2. RCOG. Report of the RCOG Working Party on Prophylaxis Against hromboembolism in Gynaecology and Obstetrics. London: Chameleon Press; 1997. 3. NICE Clinical Guidelines 92. Venous thromboembolism: reducing the risk. National Institute of Health and Clinical Excellence. 2010. 4. David C. De L’endoscopie de L’uterus. Bull Soc Obstet Pathol. 1907. 5. Clark TJ, Gupta JK. Out-patient hysteroscopy. Obstet Gynaecol. 2002;2:17–21. 6. Downes E, Al Awazzi F. How well do perimenopausal women accept out-patient hysteroscopy. Eur J Obstet Gynaecol Reprod Biol. 1993;48(1):37–41. 7. Readman E, Maher PJ. Pain relief in out-patient hysteroscopy. J Am Assoc Gynecol Laparosc. 2004;11:355–9. 8. Palmer R. Instrumentation et technique de Ia coelioscopie gynecologique. Gynecol Obstet (Paris). 1947;46:420–31. 9. Steptoe PC. Laparoscopy in Gynaecology. London: Livingstone; 1967. 10. Holt EM. Laparoscopy in gynaecology. Br J Hosp Med. 1977;18: 150–2. 11. RCOG. Special skills training in obstetrics and gynaecology. Report of RCOG Working Party; 1999.

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Im a g ing in G yna e c o lo g y

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Anju Sahdev, Rodney H. Reznek

Intro duc tio n Imaging plays an integral and diverse role in the investigation and management of patients with gynaecological disorders. In gynaecological malignancies, it is valuable in diagnosis, staging, planning treatment, surveillance, assessing response to treatment, evaluating complications and identifying recurrent gynaecological cancer. Evaluation of patients with postmenopausal bleeding, investigating suspected adnexal masses, pre-laparoscopic evaluation of pelvic endometriosis or pelvic pain, and diagnosis of early pregnancy and post-partum problems are just some of the applications of imaging in benign gynaecological and pregnancy-related disorders. In patients with malignancy, imaging plays a vital part in monitoring treatment response often acting as a surrogate endpoint following chemotherapy and radiotherapy for drug trials. A wide range of techniques including plain radiography, contrast studies, ultrasound (US) and cross-sectional techniques of computed tomography (CT) and magnetic resonance imaging (MRI) are widely applied in different stages of management in a patient with gynaecological cancer. Recent advances in functional and molecular imaging have widened the scope and applications of imaging by combining exquisite anatomical detail from cross-sectional imaging, particularly MRI of pelvic organs, with information of tissue and cellular activity obtained by scintigraphy and molecular imaging. In investigating benign disease, US and MRI are the recommended imaging modalities as they do not carry a radiation burden. In this chapter, we provide a brief description of the basic principles of the different frequently used modalities and outline recent advances in imaging. We discuss the optimal use of imaging as applicable to individual gynaecological cancers with emphasis on detection, staging, planning and monitoring treatment and identifying recurrent disease. We discuss the use of imaging in the investigation and management of endometriosis and fibroid disease.

Im a g ing Te c hniq ue s PLAIN FILM RADIO G RAPHY AND C O NTRAST STUDIES Plain film radiography relies upon the degree of X-ray absorption (attenuation) of an X-ray beam passed through the

body part to be imaged which in turn depends on the atomic density and thickness of material. Dense materials like bone and contrast agents (iodine and barium) attenuate most X-rays whilst air attenuates few within the applied beam. Once X-rays have travelled through the material they are ‘collected’ on to an X-ray film or onto a phosphor screen in digital systems. In conventional radiographs, less dense materials like air appear black and the converse is true for dense materials, which will appear white. Conventional radiographs are now almost universally obtained as digital images. The basic principle of digital imaging is the same as conventional radiography but utilises digital apparatus. The radiograph is produced on a phosphor screen and then read by lasers transferring the image onto laser film or displayed onto television monitors. The images can then be stored onto local digital networks or patient archive systems (PACS). The benefit of digital radiography is the varied forms of image output, long-term storage and distribution of images. As digital images can be manipulated and post processed, technically poor images do not require repeat X-rays saving patients unnecessary radiation exposure. Conventional techniques used for patients with gynaecological cancer include plain films of the chest, abdomen and pelvis, intravenous urograms (IVUs) and barium studies. Plain films retain only a minor role in gynaecological disorders. Plain abdominal X-rays are used to assess postoperative bowel status, in particular for evaluation of bowel obstruction. Calcification in dermoid cysts, peritoneal deposits from mucinous ovarian carcinomas, incidental renal calculi and assessment of intravenous catheters and urinary stents are other common indications in gynaecological practice (Fig. 4.1). Chest X-rays are useful in the detection of pulmonary and mediastinal nodal metastases, pulmonary infective and inflammatory diseases, cardiomegaly and pleural effusions (Fig. 4.2). The main disadvantage of plain films is poor sensitivity as the inherent contrast resolution is too poor to allow separation of soft tissue structures. Lesions have to be significantly larger in size for detection on plain films compared to cross-sectional imaging. Intravenous urography outlines the urinary tract following administration of intravenous iodinated contrast media. Intravenous urograms assist gynaecological surgery by demonstrating the number of ureters, their location and course in relation to the pelvic organs, demonstrating ureteric and renal obstruction or postoperative ureteric injury (Fig. 4.3). In many institutions, conventional IVUs have been replaced by CT

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Fig. 4.1: Abdominal radiograph: 34-year-old woman following a left oophorectomy. The AXR shows surgical clips in the left adnexa with small pockets of free air around the clips (white arrow). The transverse colon is dilated and clinically the patient had no bowel sounds in keeping with a postoperative ileus. Fig. 4.3: Intravenous urography (IVU): Single full length 15 min post-contrast łlm from an intravenous urogram series showing bilateral unsuspected duplex collecting systems with bilateral double ureters (arrows).

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Fig. 4.2: Chest radiograph: 76-year-old woman with endometrial carcinoma. The CXR shows two large metastases in the right lower zone (arrows).

IVUs. CT IVUs provide information regarding the renal parenchyma and the collecting system, increasingly replacing both renal ultrasound and IVUs in the investigation of suspected renal disease. The procedure requires the administration of intravenous contrast followed by an abdominal and pelvic CT after a delay of 15–20 minutes. This displays the renal collecting system, ureters and bladder opacified by the contrast media. CT IVUs have the added advantage of visualising and detecting abnormalities in the whole abdomen, pelvis and retroperitoneum. In gynaecological disease, obstructing abdominal or pelvic masses, retroperitoneal nodal disease and congenital variants of the kidneys can all be imaged on a single investigation (Fig. 4.4). However like IVUs, CT IVUs require administration of intravenous contrast media and therefore cannot be used in patients with iodine allergy or during pregnancy. In these patients, magnetic resonance urography provides equally good detail and avoids both radiation and contrast media (Fig. 4.5).1 Barium bowel studies, particularly double contrast barium studies, utilise the contrast between barium-coated mucosa

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Fig. 4.4: CT IVU in a patient with frank haematuria. Full length coronal CT reconstruction from a CT IVU examination. The intra-renal collecting system, ureters and bladder are opaciłed by contrast. There are bilateral clubbed calyces (black arrows) and ‘pencil in cup’ deformities indicating papillary necrosis. CT provides information regarding the entire collecting system and examines the kidneys and the entire abdomen and pelvis in a single examination.

against air within the bowel lumen for detection of mucosal lesions. Soluble contrast enema studies are utilised in the diagnosis of bowel obstruction, postoperative ileus, anastomotic leaks and fistulae (Fig. 4.6). Soluble contrast replaces barium in postoperative patients as aspiration or leakage of barium into the peritoneal cavity causes irreversible deposition of barium in the tissues. Conventional bowel contrast studies are increasing being replaced by endoscopy, CT and MRI.

ULTRASO UND Ultrasound has many uses in gynaecology. It is often the first and only imaging modality used to demonstrate gynaecological anatomy and to evaluate physiological and pathological changes. Pelvic ultrasound may be performed by transabdominal, transvaginal, transrectal or transperineal approach. In medical imaging, ultrasound (frequencies between 2.5 and 20 Megahertz) is generated by piezoelectric crystal elements in transducers that convert an electrical signal into ultrasound and once reflected from tissues, back into electrical signal. A thin layer of acoustic jelly is placed over the area to be imaged in order to obtain effective acoustic coupling between the skin and transducer. When the transducer is in contact with skin or

Fig. 4.5: Magnetic resonance urography (MRU): Coronal thick section heavy T2-weighted image from a 27-year-old woman who was 32 weeks pregnant. The patient presented with right-sided loin pain. There is right-sided hydronephrosis and hydroureter (white arrows). The ureter tapers smoothly to the pelvic brim where it is compressed by the gravid uterus. No łlling defects or ureteric meniscus is seen to suggest calculi. The appearances show the typical appearances of hydronephrosis of pregnancy with complete assessment of the kidneys, ureters and bladder without radiation or iodine-based contrast media.

mucosal surface and a voltage pulse is applied across the transducer, piezoelectric crystals vibrate, generating sound waves transmitted through the body. The reflected sound waves induce a voltage across the transducer and are converted into a grey scale image. Soft tissues reflect more echoes than fluid and therefore appear brighter (or hyperechoic) while fluid appears dark (or hypoechoic). The elapsed time for the wave to return allows estimation of distance or depth providing spatial information in construction of the image. Bone and air reflect all sound and therefore structures beyond cannot be imaged. This is B-mode ultrasound. Vascularity in soft tissues and the integrity of blood vessels may be assessed using Doppler ultrasound. The Doppler effect is shift in frequency of a wave when the source moves relative to the receiver, e.g. blood flow in vessels. When blood flows

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Fig. 4.7: Transabdominal ultrasound of the pelvis: The full bladder acts as an acoustic window to allow imaging of the deep pelvic structures. The fundus of the uterus (dashed arrows) and both ovaries (solid arrows) are seen on transabdominal ultrasound but detailed anatomical evaluation is limited. Fig. 4.6: Barium follow through with serosal disease. 56-year-old woman with ovarian cancer and known serosal disease presented with symptoms of intermittent small bowel obstruction. The barium follow through was performed to identify the site and length of small bowel involvement to plan surgery. There are distal jejunal and proximal ileal loops with bowel wall irregularity (arrows) and wide separation of the bowel loops due to the serosal disease. The patient did not have acute obstruction at the time of the study.

towards the transducer, reflected sound wave has a higher frequency than the transmitted frequency. Conversely, when blood flows away, reflected wave has a lower frequency. This frequency shift can be measured and blood flow velocity and direction can be calculated. When pulsed Doppler is applied the ultrasound transducer emits bursts of sound between which it remains quiet to receive reflected sound. This allows the combination of B-mode US imaging and a Doppler trace (duplex scan), providing depth, site and velocity information of flowing blood.2

Transabdominal Ultrasound (TAUS) Transabdominal ultrasound is performed with a full bladder which provides an acoustic window to visualise pelvic organs. This utilises curvilinear and linear transducers to provide a global view of the pelvis. It is useful to interrogate the bladder for bladder dysfunction, abnormal bowel loops, pelvic side wall for enlarged nodal disease in patients with malignancy and adnexal masses. In patients unable or unwilling to undergo transvaginal US, TAUS can provide limited anatomical detail of the uterus and pre-menopausal ovaries (Fig. 4.7). 42

Intracavity Ultrasound Intracavity US is performed using small transducers that can be introduced into body cavities. The commonest gynaecological applications are transvaginal ultrasound (TVUS) and transrectal ultrasound (TRUS). Intracavity US utilises high-frequency (5–12MHz) ultra-small curved transducers that have a small field of view (a few centimeters only) but provide high-resolution images (Fig. 4.8). This allows accurate estimation of the endometrial thickness in patients with post-menopausal bleeding and detects endometrial polyps and masses (Fig. 4.9). Transvaginal ultrasound provides exquisite detail of ovarian follicles and their physiological development. It provides detailed assessment of small ovarian cysts and has a high sensitivity for detecting ovarian malignancy (Fig. 4.10). In the assessment of early pregnancy, TVUS is the first line investigatory modality. It is used for confirming normal uterine pregnancy, excluding or confirming ectopic pregnancy and for estimating fetal age and monitoring fetal growth.

Transrectal Ultrasound Transrectal ultrasound is used to guide transvaginal interventional procedures, such as endometrial ablation and intracavitary placement of radioactive sources. Transanal ultrasound provides high-resolution images of the anal sphincter, providing images of the internal and external sphincter. This documents the site and extent of sphincter injury, usually an obstetric injury during child birth in women (Fig. 4.11).

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Fig. 4.8: Transvaginal ultrasound of the pelvis: Transvaginal ultrasound provides higher resolution images of the ovaries than transabdominal ultrasound. The ovarian stroma (asterix) and the Ńuid-łlled ovarian follicles (arrows) can be evaluated in detail. The number, distribution and nature of the ovarian follicles and cysts can be evaluated in detail. The images show an increase in stromal volume and stromal echogenicity. The ovarian follicles are arranged peripherally within the ovary and the appearances of the stroma and follicles represent polycystic ovaries.

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Fig. 4.9: Transvaginal ultrasound of the pelvis: Transvaginal highresolution image of the uterus allows detailed evaluation of the myometrium and endometrium. A hyper echoic endometrial mass is demonstrated in the endometrial cavity (arrows). The smooth endometrial–myometrial interface suggests a benign endometrial polyp. This was conłrmed at histology.

Ultrasound Contrast Agents (UCA) Ultrasound contrast agents are micro gas bubbles which when exposed to an US beam, reflect sound several times more than the reflection from blood alone. Contrast agents currently in diagnostic use have a micro-bubble structure consisting of inner gas bubbles and an outer protein shell. They remain within blood vessels and display parenchymal microvasculature with real time enhancement. The contrast agents are administered to the patient via a peripheral vein and ultrasound

(b) Fig. 4.10: Transvaginal ultrasound of the ovaries. (a) A transvaginal image showing a 3 cm ovarian cyst. The cyst has a small 6 mm solid nodule (arrow). (b) A Doppler image of the cyst shows increased vascular Ńow in the base of the nodule. Surgical removal of the cyst revealed a serous borderline adenocarcinoma of the ovary.

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(b) Fig. 4.11: Transrectal ultrasound showing (a) normal anatomy, (b) anal sphincter defects (by courtesy of Prof. Clive Bartram).

of target organs is performed immediately and at timed intervals. After injection, UCA traverse even the smallest capillaries and can be used to detect lesions not seen on conventional US. The assessment of micro-bubble enhancement requires contrast-specific US software which is readily available with newer US machines. In gynaecological imaging, UCA are used to perform US hysterosalpingograms to establish tubal patency without the use of radiation-based fluoroscopic techniques.3 Ultrasound contrast agents have also been used to improve the performance of US in the detection of hepatic metastatic disease and in the characterisation of adnexal masses.4

contrast resolution than plain radiography and is able to separate 2000 or more densities compared to about 20 on plain films. Computed tomography images are generated by computers as a grey scale representation of anatomy and the computer allocates electronic CT values to all structures within the scanned area and arranges them as a spatial image. These CT numbers called attenuation values are measured in Hounsfield units (HU) and calculated based on X-ray absorption of tissues compared to water. To generate a scale, water has an allocated Hounsfield number of 0 HU, air –1000 HU and bone +1000 HU. Fat measures between –80 and –100 HU, the normal pre-contrast liver measures between 40 and 60 HU. Although the tissue contrast of CT is good, this can be improved even further by use of oral and intravenous contrast media. Oral contrast medium outlines lumen of bowel allowing better separation of normal bowel from mesenteric, serosal or peritoneal disease, useful in the assessment of disseminated ovarian or endometrial cancer (Fig. 4.12). Intravenous contrast media is administered usually into a large peripheral vein, commonly in the antecubital fossa, at variable rates. Traditionally the term ‘enhancement’ refers to the appearance of tissue following intravenous injection of contrast media. The major advantage of CT is that it provides very highquality images of different organ systems with little or no overlap. It separates normal from abnormal tissues and can provide limited physiological information by means of quantitative measurements of enhancement and perfusion, blood volume and vessel permeability using intravenous contrast agents. It is cost effective, widely available and an easily reproducible technique. Its major disadvantages are a significant radiation burden, CT accounting for the largest proportion of medical radiation exposure in the Western world. Intravenous iodine-based contrast agents are nephrotoxic particularly in

C O MPUTED TO MO G RAPHY Computed tomography (CT) is presently the most widely used imaging tool in the investigation of all patients with cancer. Images are acquired using differential X-ray absorption within the body. X-ray absorption is dependent on the tissue atomic density and thickness. The X-ray beam is narrow and passes through a thin section of the body at a time. After travelling through the patient, the beam is collected by detectors which are capable of differentiating very subtle differences in tissue density. Computed tomography therefore has much greater 44

Fig. 4.12: Axial CT acquired for staging from a 63-year-old woman with mucinous adenocarcinoma of the ovary. The CT is acquired after ingestion of oral contrast media to separate the bowel lumen from bowel wall and serosa. This allows the detection of diffuse serosal disease (A arrows) particularly along small bowel serosa. The oral contrast also allows better distinction of bowel loops from omental and mesenteric deposits (B arrows and C arrow head).

Imaging in Gynaecology patients in renal failure, where they are usually avoided except under particular circumstances. They can cause mild allergic reactions to anaphylaxis causing death.

Multidetector Computed Tomography Recently, the ability to acquire data from more than one slice simultaneously has been developed using parallel rows of detectors. Spiral scanners are now capable of obtaining between 4 and 256 slices in a single X-ray gantry rotation. Data is therefore obtained much faster than a single slice spiral scanner. The advantages of multidetector CT include fast scanning times particularly useful in paediatric patients where sedation or general anaesthesia may be avoided or used for significantly less time. The entire chest, abdomen and pelvis can be scanned in less than 1 minute. Much thinner slices can be obtained providing a greater spatial and temporal resolution and a reduction in partial volume effects. Post processing of data allows exquisite 3D reconstruction, multiplanar image reconstruction, virtual endoscopic procedures (CT intravenous urograms, virtual CT colonography, bronchoscopy and cystoscopy) and multi-organ and limb angiography (Figs. 4.13 and 4.14).

Fusion/Co-Registration Techniques Developments in CT software have allowed co-registration of other imaging modalities onto CT images. This is increasingly useful in combining functional images from nuclear medicine techniques and PET on to anatomical CT images. In gynaecology,

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(b) Fig. 4.13: Coronal CT reconstructed image showing extensive metastatic disease in the abdomen and pelvis in a patient with ovarian carcinoma. The coronal reconstruction utilises the ideal plane for demonstration of subdiaphragmatic, upper abdominal, para-colic and pelvic deposits. The CT shows multiple sites of disease. A: left subdiaphragmatic deposit, B: gastro-hepatic ligament inłltration, C: Peri-hepatic deposits, D: Morrison’s pouch deposits, E: Right para-colic peritoneal deposits, F and G: complex solid cystic ovarian carcinomas.

Fig. 4.14: Bowel obstruction in ovarian cancer. (a) Axial abdominal CT showing a dilated small bowel loop with faecalisation (block arrows). At the site of obstruction there is a narrowed segment which is tethered to a metastatic serosal deposit (dashed arrows). (b) Coronal reconstructed CT image of the abdomen and pelvis. This demonstrates a large inłltrative mass within the small and large bowel mesentery. This results in an atonic łxed bowel contributing the bowel obstruction.

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Section A | Introduction, Anatomy, Pre-op. Diagnosis and Management, Imaging, Skill Learning, Postop. Care fusion of CT and MRI imaging is particularly useful in mapping cervical cancer, which is best demonstrated on MRI but receives CT guided radiotherapy. Accurate co-registration allows targeted radiotherapy and avoids side effects of radiotherapy to bowel, bladder and other pelvic structures.

MAG NETIC RESO NANC E IMAG ING

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Magnetic resonance imaging (MRI) is a non-ionising radiationbased imaging modality that utilises weak radio-wave signals emitted by body tissues when the body is placed in a strong magnetic field and radio frequency (RF) pulses are applied. These emitted signals are converted into grey scale images. The signals are predominantly associated with water protons, and to a lesser extent fat protons. Within very strong magnetic fields (like MRI magnets) spinning hydrogen protons in the body, align themselves with the external magnetic field. When a short RF pulse with the same frequency as hydrogen protons is applied, the magnetisation direction is altered and all protons align themselves in the same direction (in-phase). As soon as the RF pulse is stopped, the energy gained by the protons begins to decay. This loss of energy depends on two factors: (a) the protons return to their original alignment in the static magnetic field (spin-lattice relaxation) and (b) interactions of nearby protons disrupting local proton magnetic fields (spin-spin relaxation). The spin-lattice and spin-spin relaxation signals are mathematically converted into T1 and T2 relaxation times, respectively. T1 relaxation is short in heavy molecules such as fat and protein, while smaller molecules with more free protons have long T1 relaxation. T2 relaxation depends on dissipation of magnetic energy into the local environment. Solids, bone and

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large rigid molecules do not move and have very short T2 relaxation times unlike free water protons, which have a long T2 relaxation. Image generation relies on varying the time of applied RF pulses and the time to collect returning signals. To determine the type of image (T1 or T2 weighted images), signals can be obtained at times when tissue T1 or the T2 effects predominate. Recent advances in receiver coil technology and rapid sequences have allowed faster imaging times and improved image quality. The major advantages of MRI are its lack of radiation, lack of iodine-based contrast media and its superior tissue contrast resolution. It provides exquisite anatomical detail and on highresolution images delineates endometrial and cervical pathologies better than TVUS (Fig. 4.15). It has a natural high contrast between tissue allowing MRI to accurately separate fat, blood and fluid. This ability makes MRI ideally suited for the characterisation of adnexal masses (Figs. 4.16 and 4.17). Its multiplanar imaging abilities were an advantage but this importance has diminished with the advent of multidetector CT. It has no known in vivo adverse effects on embryo, fetal tissues or the ovaries. The main disadvantages of MRI include longer imaging times than CT, less widespread availability and a need for specialist training. The combination of a long period in a closed space and noise generated by loud radiofrequency pulses can result in claustrophobia in adults and the studies are difficult for children to tolerate. The patients are required to lie still for the duration of the study and motion severely degrades the images usually resulting in non-diagnostic studies. The performance of MRI is also highly protocol and technique dependent. To achieve reproducibility, imaging protocols need to be standardised.

(b)

Fig. 4.15: (a) Sagittal T2-weighted image from a 24-year-old woman with adenocarcinoma of the cervix. A large inłltrative mass is seen replacing the cervix with proximal extension and invasion of the myometrium (arrows). There is stenosis of the internal os with a resultant hydrometra (asterix). (b) Axial-oblique T2-weighted image acquired to obtain a cross-sectional image of the cervix. The tumour is seen extending into the left parametrium (arrows) in keeping with a large FIGO stage IIB carcinoma.

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(a)

(b)

(c)

(d)

Fig. 4.16: MRI of left ovarian dermoid cyst. (a) Axial T2-weighted image of the pelvis. There is a 7 cm high T2-signal intensity cystic ovarian mass with central soft tissue. (b) Axial T1-weighted image showing the cystic ovarian mass has high T1-signal intensity material. (c) Axial T1-weighted and fat-saturated image. This shows loss of the high T1-signal intensity after application of fat saturation sequences indicating the presence of fat in the cystic ovarian mass. This detection and characterisation of fat in cystic ovarian masses is typical of ovarian dermoid cysts.

The specific contraindications to MRI are summarised in Table 4.1. MRI contrast agents are paramagnetic molecules used to improve the natural contrast between soft tissue structures. Many different agents are used in clinical practice including gastrointestinal, intravascular (blood pool), tumour-specific, hepatobiliary and reticuloendothelial contrast agents. The most frequently used group of contrast agents are gadolinium based, intravascular blood pool agents which are administered intravenously usually in an antecubital vein and remain in the intravascular compartment. Gadolinium agents can assess tissue perfusion and provide information about capillary permeability. They show the extent of tumour neovascularity and associated permeability changes. The blood pool properties make them suitable for angiography. Angiography of pelvic vessels is useful for assessment of fibroid vascularity, investigation of chronic pelvic pain and tumour perfusion.

Gadolinium allergy and previous or present history of nephrogenic systemic fibrosis (NSF) are the absolute contraindications in clinical use. NSF results in systemic irreversible fibrosis of skin and viscera and has been linked to the use of gadolinium in people with pre-existing renal failure. The symptoms of NSF include tightening, swelling and symmetrical red patches of the skin, thickening of the skin and restriction of movement around joints, calcification, itching and sharp pains in affected areas including bone, muscle weakness and yellow plaques near the eyes. Presently, no curative treatment is available for NSF but symptom control is the mainstay of patient management. Relative contraindications for gadolinium use include pregnancy, lactation, hepatorenal syndrome, chronic hepatic disease, previous anaphylaxis to gadolinium and significant renal impairment with an eGFR below 30. Diffusion-weighted imaging (DWI) is a relatively new inclusion in gynaecological MR imaging. This constitutes MRI

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(c) Fig. 4.17: MRI of right ovarian endometrioma. (a) Axial T2-weighted image of the pelvis showing a 9 cm right ovarian cyst with intermediate signal intensity. The cyst has a smooth wall and no complex internal features. (b) Axial T1-weighted image showing the cyst has high T1-signal intensity material. (c) Axial T1-weighted and fat-saturated image. The high-signal intensity retains very high signal, a characteristic property of blood. Overall the appearances are of an endometrioma.

Table 4.1: Safety of MRI Absolute contraindication: • Metallic intra-ocular foreign bodies • Non-MRI compatible cerebral aneurysm clips • Non-MRI compatible cardiac pacemakers • Non-MRI compatible neurostimulator devices or cochlear implants • Patients with metallic surgical clips up to 6 weeks after surgery Relative contraindication: • First trimester of pregnancy • Joint prostheses are generally acceptable but may cause susceptibility artefacts in the images and patients may experience discomfort due to heating of metallic prosthesis

sequences that use Brownian motion of proton molecules to evaluate different tissues. Brownian motion of protons is reduced with increasing cellular density/cell membranes and increasing extracellular macromolecules. This reduction of motion is seen as increasing signal intensity on diffusionweighted images. The degree of proton motion can be quantified by the Apparent Diffusion Coefficient (ADC value). DWI is used in association with routine MRI sequences to improve the overall performance of MRI. The advantageous applications of DWI in gynaecological disease include assessment of residual 48

or recurrent cervical cancer following chemoradiotherapy, detection of peritoneal deposits in ovarian cancer, effectiveness of uterine artery embolisation in fibroids and for the distinction between benign post-surgical changes and recurrent disease following surgery.5–7 The exquisite anatomical detail, the ability to detect early pathologies and the lack of radiation burden makes MRI an adjunct to US in imaging gynaecological conditions. The role of MRI in gynaecological conditions is continuously evolving. It now has an established role in gynaecological malignancies discussed later in the chapter.

NUC LEAR MEDIC INE Nuclear medicine imaging has contributed significantly in diagnosis, treatment planning and evaluation of response in patients with cancer with the development of modern scintigraphy techniques. It utilises the body’s own normal and abnormal biochemical and physiological pathways making it a form of functional imaging. The patient is injected with a gammaemitting labelled tracer and its distribution after a period of time is detected by modified gamma cameras containing scintillation crystals which are read by photomultiplier tubes. The

Imaging in Gynaecology patient lies under the gamma detector system (camera) for 20–60 minutes and the whole body distribution of the tracer is mapped into an image by applying mathematical algorithms. The image is most commonly a planar image but if tomographic techniques are applied, single-photon emission CT (SPECT) and positron emission tomography (PET) images can be obtained.

Positron Emission Tomography PET is a nuclear medicine modality that provides quantitative tomographic images allowing non-invasive functional imaging. It has an increasingly important role in oncology for diagnosis, staging, predicting response to treatment and in the detection of recurrent disease. It utilises biochemical metabolites (commonest 2-deoxy-d-glucose), labelled with beta-emitting radiotracers (18-Fluorine) that are injected intravenously. Both glucose and deoxyglucose enter cells via cell glucose transporters and undergo phosphorylation but while glucose undergoes further enzymatic breakdown, deoxyglucose becomes trapped in intracellular compartments. Cancer cells have increased glucose cell membrane transporters and intracellular phosphorylation enzymes thereby take up and trap more glucose and deoxyglucose than normal cells. It must be remembered that FDG is not a specific marker for cancer cells and activated macrophages are also known to exhibit high tracer uptake. This has significant implications in the analysis of PET studies as active infection and cancer can behave similarly. The 18Fluoro component undergoes beta decay in the body producing a high-energy positron. Once the positron slows down it produces two gamma rays which are emitted back-to-back and have energy of 511 KeV each. These decay events are detected by coincidence registration of gamma quanta. The images created represent the metabolic activity of underlying tissues. Positron emission tomography has an advantage over conventional nuclear medicine in that it allows measurements of tracer concentrations within tissues providing the most commonly used clinical measurement index, the standard uptake value (SUV), which compares lesion activity concentration to average activity concentration of the whole body. SUV values have been utilised to differentiate between benign from malignant lesions and prognosticate survival in patients with cancers. In general, the higher the SUV the poorer the outcome, and changes in SUV before and after chemotherapy have been compared to assess the effectiveness of chemotherapy agents.

PET-CT In clinical oncology, diagnosis and staging of cancer are traditionally based on CT imaging which relies on detecting anatomical alteration of normal tissues. However in cancer, functional changes precede anatomical alteration. PET has a high sensitivity for detection of this functional change but its spatial resolution for anatomical localisation is poor. Over the past decade software-based algorithms have been developed

which allow fusion and combined display of CT and PET images. However these require superimposition of data acquired retrospectively and normal variations in position and activity of bowel, respiration and cardiac function contribute to correlation errors. The alternative solution of hardware fusion has created PET-CT. This allows acquisition of CT and PET data in a single examination without altering patient position between scans. In clinical practice this involves injecting patients with 18-FDG PET tracers at least one hour prior to the start of the combined PET-CT. Contiguous spiral CT scans are acquired through the area of interest. After completion of the last spiral CT image, the patient is advanced for PET emission images acquired in a caudal-cranial direction taking up to 1 hour. Unlike conventional CT, due to the long duration of the combined acquisition, patients have their arms by their side and breathe gently during the scan. Once the CT data collection is complete, it is sent to the PET console for attenuation and scatter correction. Once corrected, PET and CT data can be viewed separately, side-by-side or as a fused image. Early results show that combined PET-CT improves diagnostic accuracy compared to CT or PET alone.8 The main advantage of PET-CT is a whole body imaging technique allowing the early detection of distant metastases in gynaecological malignancies (Fig. 4.18). The combination with CT reduces false positive results due to physiological FDG uptake in tissue, such as brown fat and muscle.

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INTERVENTIO NAL TEC HNIQ UES Interventional radiology is altering the management of several gynaecological disorders and complements surgical and medical treatment of patients. The aim is to provide imageguided, minimally invasive alternatives to traditional surgical and medical procedures in suitable patients. Procedures include image-guided biopsies, nephrostomies and antegrade ureteric stenting for urinary obstruction, pre-operative insertion of inferior vena caval filters in high-risk patients unable to be adequately anti-coagulated to prevent pulmonary emboli, and imaging-guided therapy such as endometrial ablation, embolisation for post-partum haemorrhage, fibroid embolisation, high-frequency ultrasound treatment (HIFU) of fibroids and recanalisation of Fallopian tubes (Fig. 4.19). Percutaneous radiofrequency ablation techniques of liver and lung metastases have survival benefits equivalent to surgical metastectomy but are still sparingly used in gynaecological malignancies.9 Procedures which previously may have required major surgery can now be performed by interventional radiologists as day case procedures. Interventional procedures may be conducted using several imaging modalities. Clearly radiation-free modalities, US and MRI, are preferable to minimise radiation exposure of highly radiosensitive ovaries and endometrium (Fig. 4.20). Fluoroscopic and CT guidance is reserved for embolisation techniques, deep pelvic biopsies or drainages and emergency procedures. 49

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Ro le o f Im a g ing in G yna e c o lo g ic a l C a nc e rs O VARIAN C ANC ER

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(b) Fig. 4.18: PET-CT: 76-year-old woman with grade 3 endometriod adenocarcinoma of the endometrium. (a) Coronal whole body maximum intensity projection 18F-FDG PET image showing an FDG avid lung lesion in keeping with a metastasis during routine surveillance (arrow). The advantage of PET-CT as a whole body imaging modality allows the detection of unexpected distant metastases. (b) Fused CT and 18F-FDG PET image conł rming the intrapulmonary location of the metastasis.

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Imaging has an important role at presentation for confirmation of diagnosis, pre-operative assessment of disease, postoperative or post-chemotherapy assessment of residual disease and for detection of recurrent disease. Ultrasound, particularly transvaginal ultrasound (TVUS) is the commonest modality used to identify and characterise pelvic ovarian masses at presentation. This is usually during investigations for pelvic pain, menstrual disturbances, as part of investigations of a raised serum CA125 or in advanced disease with ascites and a palpable pelvic mass. Criteria for characterising malignant masses on ultrasound have been described and include masses larger than 10 cm, the presence of soft tissue nodules (soft tissue components) and vegetations, thickened irregular walls, thickened nodular septae, presence of ascites and peritoneal nodules. The sensitivity and specificity of ultrasound including the addition the Doppler ultrasound has been reported between 85%–97% and 56%–95%, respectively.10 In the authors’ experience, the specificity of ultrasound is highly variable and is closer to 56% in clinical practice. The main pathologies lowering the specificity of US are dermoid cysts, endometriomas, inflammatory pelvic disease and fibroids. Contrast-enhanced CT relies on the same criteria as TVUS and has accuracy in detection of ovarian masses of up to 95% and in distinguishing benign from malignant disease of 66%.11 As for US, the specificity of CT is poor. MRI with gadolinium enhancement has also been shown to have a high sensitivity (95%) and a substantially better specificity of (93%) and accuracy (91%) than TVUS for malignancy in ovarian masses.12 With its superior specificity, MRI is now routinely used for the characterisation of sonographically indeterminate adnexal masses. Its role has been formally defined by the female imaging subcommittee of the European society of urological radiologists.13 Adnexal masses may be sonographically indeterminate if the lesion cannot be confidently placed into either a benign or malignant category, if the site of origin is unclear or the mass is entirely solid. MRI is recommended in young women with a normal or minimally raised CA125 and a low or intermediate risk of malignancy index (RMI). In these patients, the role of MRI is to confirm benignity in the adnexal mass. Surgical resection is recommended for lesions that remain indeterminate on MRI.13 The advantage of MRI is a high sensitivity and specificity in characterising fat, blood and fibrous tissue difficult to identify definitively on other modalities. MRI provides better anatomical localisation of adnexal masses to organs of origin, e.g. ovarian, tubal or uterine. MRI evaluates the whole pelvis excluding non-gynaecological masses, retroperitoneal pathology, nodal disease or bowel pathology and detects related features of malignancy like ascites, peritoneal disease and visceral metastases. Surgical staging is the gold standard but inaccurate in 30%–40% with upper abdominal disease being the most

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Fig. 4.19: Uterine łbroids before and after uterine artery embolisation. (a) Coronal T2-weighted image of the uterus showing innumerable low T2-signal intensity łbroids (white arrows) within the uterus. In particular, two large submucosal łbroids are seen extending into the endometrial cavity and distorting the cavity (dashed arrows). (b) Coronal T1-weighted image with fat saturation and intravenous gadolinium contrast enhancement. All the łbroids are demonstrated as vascular enhancing masses thereby suitable for embolisation (arrows). (c) Coronal T2-weighted image acquired 3 months after uterine artery embolisation. The multiple łbroids have decreased in size, in particular the sub-mucosal łbroids which no longer distort the endometrial cavity (dashed arrows). (d) Coronal T1-weighted image with fat saturation and intravenous gadolinium contrast enhancement. Most of the uterine łbroids are now avascular and non-enhancing in keeping with a good response following embolisation (arrows).

frequent site of occult disease. Intravenous and oral contrastenhanced CT of the abdomen and pelvis is the commonest imaging modality used for radiological pre-operative staging or imaging prior to and following chemotherapy. Computed tomography is useful in detecting ascites, pleural effusions, tumour involvement of intra-abdominal viscera, mesentery, peritoneal reflections and omentum. The major limitation of CT is its inability to detect peritoneal deposits below 1 cm and

this drops the staging accuracy of CT between 70% and 90%. MRI with gadolinium enhancement has similar accuracy to CT in detecting peritoneal disease and does not improve the detection of peritoneal disease below 1 cm. It has better accuracy detecting implants on bowel serosal and invasion of the sigmoid colon, bladder and rectum.14,15 The performance of MRI in the detection of peritoneal deposits improves with the addition of functional imaging, in particular diffusion-weighted 51

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Fig. 4.20: US of deep femoral lymph nodes in a patient investigated for recurrent vaginal squamous cell carcinoma. A large lymph node mass is demonstrated in the deep femoral region (dashed arrows). For histological conłrmation of recurrent carcinoma, a cutting biopsy needle is introduced into the mass under ultrasound guidance (arrows) and tissue core biopsy is obtained. Direct visualisation of the needle allows precise placement of the needle tip avoiding adjacent vessels and areas of necrosis within the nodal mass.

imaging, to a high 90% sensitivity and 88% specificity.16 Increasingly, in patients with irresectable tumour at presentation, CT and US can be used to provide omental or peritoneal tissue biopsy to confirm the diagnosis prior to adjuvant chemotherapy. Response to treatment may be assessed by serum CA125 levels, by non-invasive imaging (CT or MRI) or by invasive laparoscopy or laparotomy. Computed tomography is most frequently used to document treatment response. Localised disease in the pelvis at the vaginal vault and the Pouch of Douglas is better assessed by MRI. FDG-PET has been recently used in staging primary disease and detecting recurrent disease. At present the literature reports no improved sensitivity of FDG-PET alone or in conjunction with CT compared to conventional CT alone. In fact FDG-PET is inferior to CT in the demonstration of small peritoneal deposits. False negative FDG-PET has also been reported early after completion of chemotherapy.17 Current recommendations are the routine use of contrast-enhanced CT with PET-CT reserved for problem solving.18

ENDO METRIAL C ANC ER Endometrial biopsy is necessary to establish the diagnosis of endometrial cancer. In endometrial cancer, TVUS shows an increase in endometrial thickness, heterogeneous echotexture and an irregular poorly defined edge. Using endometrial thickness of less than or equal to 5 mm in post-menopausal women with vaginal bleeding, TVUS has a very high negative 52

predictive value in ruling out not only patients with endometrial cancer but also any other endometrial abnormality, such as polyps or hyperplasia.19,20 Staging of endometrial cancer is surgico-pathological requiring total abdominal hysterectomy (TAH), bilateral salpingo-oophorectomy (BSO), peritoneal washings, assessment and sampling of pelvic and para-aortic lymph-nodes. Federation Internationale de Gynécologic et Obstétrique (FIGO) recommends pre-treatment imaging evaluation of endometrial cancer with conventional imaging including barium enema, chest X-ray and intravenous urography. The revised FIGO 2009 guidelines recommend pre-operative MRI, when available, for staging and as a substitute for cystoscopy and sigmoidoscopy.21 As part of staging, TVUS has been used to evaluate the depth of myometrial and cervical invasion in endometrial cancer. The depth of myometrial invasion is an important prognostic factor in endometrial cancer, the incidence of nodal metastases increasing sharply from 3% in tumours with no or superficial myometrial invasion to 40% in tumours with deep myometrial invasion. TVUS, CT and MRI have all been used to assess myometrial invasion. The performance of TVUS is variable and operator dependent. The reported accuracies for myometrial invasion vary between 77% and 91%.22 Computed tomography including newer multidetector CT has poor sensitivity and specificity for myometrial and cervical invasion. For the detection of deep myometrial invasion the sensitivity and specificity are 83% and 42%, respectively. For the detection of cervical invasion the sensitivity and specificity are 25% and 70%, respectively. The overall staging accuracy of CT is between 58% and 76%. Computed tomography is therefore of limited value for local staging and unlikely to affect management in early endometrial cancer. In more advanced disease with parametrial and pelvic sidewall disease, CT is highly accurate in detecting local spread beyond the uterus.23 Due to its excellent tissue contrast resolution, MRI has established its role in identifying deep myometrial invasion. The use of gadolinium improves the ability to assess depth of myometrial invasion with MRI. With regards to myometrial invasion, the reported sensitivities and specificities are between 84%–87% and 91%–94%, respectively. The PPV is 87% and NPV is 91% for the identification of myometrial invasion greater than 50%.24 MRI also performs particularly well in the detection of cervical invasion and sensitivity, specificity, accuracy, PPV and NPV for cervical invasion is 80%, 96%, 92%, 89% and 93%, respectively. Several investigators have reported that macroscopic cervical invasion, detectable on MRI, imparts a worse prognosis than microscopic invasion. Therefore pre-operative assessment for cervical involvement may help in planning surgery and radiotherapy.25 Also as part of staging, extra-uterine disease including peritoneal deposits in the Pouch of Douglas, omental disease and pelvic or retroperitoneal lymphadenopathy is also readily detected on MRI. Lymphadenectomy remains a component of the surgical-pathological staging of endometrial cancer, although this is currently a topic of debate. Lymphadenectomy carries a significant complication rate of 17%–19%, requires

Imaging in Gynaecology increased anaesthetic and operating times and needs expertise of a specialised oncologic surgeon.26 The rate of pelvic lymph node involvement in Stage 1 endometrial cancer is low approximately 10%.27 Although in a recent series, nodal metastases have been detected in up to 29% of patients in intermediate to high-risk categories.27 Patient selection for primary lymphadenectomy at the time of hysterectomy is therefore presently controversial in oncological gynaecology. The ability to select patients for lymphadenectomy prior to surgery may therefore be of value. Imaging can assist in pre-operative assessment and surgical planning by predicting the depth of myometrial invasion, cervical stromal involvement, distant spread and lymph-node involvement. Pre-operative knowledge of these factors is important as patients with disease greater than FIGO (2009) stage 1A may benefit from lymphadenectomy, but the number of unnecessary lymph-node dissections can also be reduced in low-risk patients by showing that none of these factors are present. MRI has also been advocated in the detection of recurrent disease to evaluate surgical resectability. Recurrent endometrial cancer may present as a pelvic mass in the hysterectomy bed or as pelvic or retroperitoneal lymphadenopathy. Less frequently, it may manifest as peritoneal carcinomatosis. Distant metastases and early recurrent disease are usually associated with highgrade tumours and advanced stage at presentation. CT performs well in detection of recurrent pelvic disease with an overall accuracy, sensitivity and specificity of 92%, 92% and 80%, respectively. FDG-PET has been evaluated in small studies and reports promisingly high sensitivity of 96% but a low specificity of 57%. Correlation of FDG-PET with CT minimises false positive rates resulting in a higher specificity of 88%. As FDG-PET is a whole body imaging technique all comparative studies report a higher accuracy than both CT and MRI in detection of para-aortic disease bone and lung metastases.28

C ERVIC AL C ANC ER Between 85% and 95% of cervical cancers are squamous cell carcinomas arising at the squamo-columnar junction and visible on direct speculum examination as exophytic or ulcerating tumours. In older women, the squamo-columnar junction lies within the endocervical canal resulting in endophytic tumours. Transvaginal ultrasound and CT will only visualise large tumours. Magnetic resonance imaging provides highly accurate information on the morphology, size and staging of the carcinomas. On MR imaging, cervical cancers appear as hyperintense lesions on T2-weighted images and iso-intense on T1-weighted images regardless of the cell type. After administration of gadolinium, cervical tumours demonstrate early and prolonged enhancement compared to poor enhancement of the normal cervical stroma. On diffusion weighted imaging (DWI), cervical carcinoma demonstrates restricted diffusion with low apparent diffusion coefficients (ADC). The ADC values alter with treatment and this technique may have the potential to be used to predict and monitor response to therapy. The diagnosis of cervical cancer is made clinically and histologically with imaging required to stage the disease.

Both CT and MRI have been used to stage cervical cancer. The cervical carcinoma itself is not seen on CT but staging relies on identifying presence or absence of tumour in the parametrium, detecting ureteric obstruction or pelvic side wall destruction. MRI is the most accurate imaging technique overall for pre-operative staging of cervical cancer significantly better than CT (accuracy 86% versus 63%, respectively).29 MRI is also costeffective as it can replace cystoscopy, sigmoidoscopy, barium enema and intravenous urography as suggested by current FIGO staging. The main role of MRI is to separate early stage (1A-11A) disease from advanced disease by detecting parametrial extension of tumour which renders the patient Stage IIB or above. This is critical as small tumours below stage IIB can be treated surgically whilst those that are large stage 1B or stage IIB and above are treated with radiotherapy alone or combined with chemotherapy. The performance of MRI in early cervical tumours was evaluated in a meta-analysis by Bipat et al. showing MRI had a sensitivity of 93% for tumour detection and an overall staging accuracy of 86%. By comparison, clinical FIGO staging performed poorly with an overall accuracy of only 47%.30 More recently, the joint ACRIN and GOG study reported much improved clinical FIGO staging results with specificity, PPV and NPV of 99%, 91% and 84%, respectively. However in this study, final clinical staging was reported after CT and MRI findings were available, thereby strongly influencing and improving clinical staging. The primary tumour cannot be visualised on CT but can be accurately defined on MRI. Computed tomography is therefore unsuitable for assessing suitability for trachelectomy and limited for planning modern conformal radiotherapy techniques particularly intensitymodulated radiotherapy (IMRT).31 In advanced tumours, staging depends on invasion of adjacent pelvic structures, pelvic sidewall, ureters and vaginal wall. Magnetic resonance imaging criteria for pelvic side-wall invasion includes tumour less than 3 mm away from the bony side wall, vascular encasement by tumour, ureteric encasement or hydronephrosis, tumour in obturator internus, piriformis or levator ani. The meta-analysis by Bipat et al. showed that MRI had a sensitivity of 91% for bladder invasion and 75% for rectal invasion.30 One of the major advantages of visualising the carcinoma on MRI is predicting proximal extension of tumour and thereby predicting feasibility for trachelectomy. An important criterion for surgery is that the proximal end of the tumour should be at least 1 cm distal to the internal os to permit tumour-free re-anastomosis. On MRI, for detection of internal os tumour involvement, the sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV) have been shown to be 90%, 98%, 86%, 98%, respectively. Imaging, MRI in particular, is routinely used for surveillance in women who have undergone trachelectomy to detect early recurrence in order to institute timely completion curative surgery.32,33 Approximately 30% of women die of residual or recurrent cervical cancer after primary treatment. Both CT and MRI have an important role in detection of recurrent disease. The accuracy of CT is up to 85% and it is limited in differentiating post-radiation fibrosis and oedema from recurrent disease. The

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sensitivity of MRI and FDG-PET for detecting recurrent pelvic disease is a comparable 90%. The early FDG-PET results showed a very high sensitivity for extra-pelvic nodal disease (100%) but a relatively poor sensitivity (75%) and specificity (33%) for small volume lung and bone disease, where CT and MRI perform better respectively. However, later studies show a lower sensitivity (60%) of PET-CT in the detection of extracervical disease.34 The current role of PET-CT includes detection of pelvic and para-aortic nodal disease or distant metastases in patients planned for primary or secondary surgical curative resection.35,36 In most institutions, radiotherapy is delivered by CT-guided 3D conformal planning. More recently, intensity-modulated radiotherapy (IMRT), a form of 3D radiotherapy planning has been introduced. Here tumour and nodes are tracked out on either CT or MRI and radiotherapy doses are delivered in a more focused way to affected tumour tissues only. This allows a greater dose delivery to affected sites but also reduces radiation to unaffected pelvic structures limiting unwanted effects. For effective use of IMRT, gross tumour volume (GTV) and affected lymph nodes need to be mapped out accurately. The present system of IMRT relies on tumour measurements on CT. However, in our experience CT tends to overestimate the volume of the tumour and it is therefore crucial that MRI be correlated with CT to define the true GTV. The accuracy of MRI tumour volume estimation in cervical cancer has been established.32

Ro le o f Im a g ing in Be nig n G yna e c o lo g ic a l Dise a se Benign gynaecological disorders may cause significant morbidity and adversely affect quality of life. Imaging, particularly TVUS, is used for the diagnosis of fibroid disease, assessment of polycystic ovaries and for the follow-up of known benign adnexal lesions particularly dermoid cysts and endometriomas. Increasingly, applications for MRI in the assessment of extra-ovarian endometriosis and for the pretreatment evaluation of fibroid disease discriminating between patients suitable for myomectomy or fibroid embolisation have been described. TVUS also has a key role in the investigation of infertility whilst MRI is key in the evaluation of congenital malformations of the female genital tract. Hysterosalpingograms are still used in the investigation of infertility as they relative low cost, readily available and provide good anatomical detail of the endometrial cavity and Fallopian tubes. These are increasingly being supplemented by hysterosalpingo-contrast sonography (HyCoSy), which aims to replace laparoscopic procedures in assessing tubal patency. The advantage of HyCoSy is the lack of radiation and it can be carried out in an out-patient setting. In this chapter we limit our discussion to the established and emerging roles of imaging in congenital Mullerian malformations, endometriosis and uterine fibroid disease. 54

C O NG ENITAL ANO MALIES Congenital Mullerian duct anomalies in women are often asymptomatic and usually discovered incidentally except infrequently when there is obstruction of the uterine outflow. Consequently, the prevalence of congenital uterine anomalies in the general population is difficult to ascertain, but it appears to be more frequent in patients with recurrent miscarriages or infertility. In these patients, HSG is the first-line investigation being an acceptable and widely available diagnostic tool. It provides valuable information regarding the uterine cavity. HSG, however, does not evaluate the external contour of the uterus and cannot reliably differentiate between a septate and bicornuate uterus. Transabdominal or transvaginal ultrasound is used to supplement HSG. Pooled data from reports comparing 2D US and hysteroscopy suggest US has low sensitivities of under 60% in the detection of uterine anomalies but high specificities of nearly 100%.37 The combination of HSG and US provides a suitable screening tool. Increasingly 3DUS, HyCoSy, hysteroscopy and MRI are used to further evaluate anatomy when HSG and 2D ultrasound are inconclusive (Fig. 4.21). Comparative data on the performance of these techniques is still limited but small studies from single institutions show promising results. Wu et al. showed a 100% sensitivity and specificity of 3D ultrasound when compared to hysteroscopy. MRI offers a non-invasive approach of assessing the internal and external contour of the uterus.38 When compared to hysteroscopy and laparoscopy in a study with 24 patients, MRI has 100% sensitivity and 75% specificity in the detection and characterisation of Mullerian duct abnormalities (Fig. 4.22).39 The accuracy and practicality of MRI has not yet been fully determined, however, its role in screening or diagnosing congenital uterine anomalies may become more important in the future. Currently, the combination of hysteroscopy and laparoscopy remains the gold standard in the investigation of Mullerian anomalies, but the main disadvantage of this strategy is the invasiveness of the procedures.

ENDO METRIO SIS The clinical manifestations of endometriosis are protean. The majority of patients with endometriosis are thought to be asymptomatic with the commonest site of involvement being the ovaries. The morbidity associated with endometriosis includes chronic pelvic pain and infertility. Endometriosis involving the gastrointestinal tract usually involves the sigmoid colon and rectum. Endometrial implants first involve the bowel serosa but may erode the muscle and mucosa causing bowel obstruction, pain and rectal bleeding. Typically, on barium enema studies, the lesions result in an irregular contour of the bowel wall and loops of bowel may be tethered together. The commonest site of pelvic endometrial deposits is along the anterior wall of the mid rectum. Endometriosis more commonly involves the urinary tract with adhesions or endometriomas obstructing the ureters just below the pelvic brim and bladder deposits causing cyclical haematuria or chronic cystitis. Rare manifestations include intrathoracic deposits causing cyclical pneumothoraces.40 A variety of techniques including TVUS, transrectal US, CT and MRI have been used to evaluate deep pelvic endometriosis.

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(b)

Fig. 4.21: Bicornuate uterus. (a) Transverse US image of the uterus at the fundus showing two endometrial cavities (arrows). (b) 3D image of the uterus showing two endometrial cavities (arrows) with a convex myometrial contour. The appearances are typical of a bicornuate uterus.

Fig. 4.22: MRI septate uterus. Axial oblique T2-weighted image demonstrating a normal convex border of the uterine fundus (black arrow). There is a low T2-weighted septum within the endometrial cavity (white arrows) extending from the fundus to the internal os. The convex fundal border distinguishes a septate uterus from an arcuate uterus.

Microscopic and small deposits of endometriosis are not well seen on imaging and hence laparoscopy remains the gold standard for diagnosis. Scattered small deposits within the pelvis are not seen on transvaginal ultrasound or CT. Magnetic resonance imaging improves the sensitivity to 68% for lesions diffusely scattered in the pelvis, lesions typically along the posterior uterine surface and in the rectovaginal septum (Fig. 4.23).41 Surrounding active foci of endometriosis, characteristically fibromuscular hyperplasia occurs. In deep pelvic endometriosis, fibrotic changes due to inactive fibrous tissue and scarring, results in distortion of the posterior vaginal fornix, uterus and uterosacral ligaments. This

Fig. 4.23: Uterine surface endometrial deposits. Sagittal T2-weighted image demonstrating high T2-signal intensity punctate endometrial deposits along the posterior uterine surface (arrow heads) typical of active deposits of endometrial tissue. In addition there is a łbrotic band between the cervix and the anterior wall of the rectum (arrow) with a low T2-signal intensity typical of łbrosis. The left ovary is medially displaced stuck to the posterior margin of the uterus, a typical feature of extra-uterine pelvic endometriosis (black arrow). A lower segment caesarean section scar is noted (dashed arrow).

distortion is clearly seen with a high sensitivity (94%) along with extra-ovarian endometriomas and haematosalpinges (Fig. 4.24).42 The use of gadolinium contrast agents is useful to increase the sensitivity for detection of active endometrial deposits and secondly to distinguish between active endometrial tissue and fibrosis (Fig. 4.25).

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Fig. 4.24: Posterior cul-de-sac lesions. Sagittal T2-weighted image demonstrating a widened and irregular junction zone of the uterus in keeping with adenomyosis (arrowheads). The posterior vaginal fornix is superiorly displaced and the uterus is retroverted and tethered to the posterior fornix by a dense low T2-signal intensity łbrotic plaque (arrows).

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Fig. 4.25: Active extra-uterine endometriotic deposit. (a) Axial T2-weighted image showing an irregular mixed signal intensity lesion in the left sciatic canal and posterior pelvic wall (dashed arrows). The sciatic nerve is seen as the very low T2-signal intensity structure within the canal and posterior to the endometrial deposit (solid arrow). (b) Axial T1-weighted image demonstrating the irregular margins of the deposit and stranding into the surrounding fat. (c) Axial T1-weighted images with fat saturation. The deposit has punctate areas of high T1-signal intensity in keeping with haemorrhage and active endometrial tissue. (d) Axial T1-weighted images with fat saturation and following intravenous administration of gadolinium. The deposit enhances avidly typical of a deposit with active endometrial tissue.

Imaging in Gynaecology Three patterns are observed on MRI in diffuse deep pelvic endometriosis excluding endometriomas, bladder and intestinal lesions: most frequent is involvement of the rectosigmoid junction where the rectum is displaced anteriorly and converges with the posterior uterus. The second most frequent pattern is linear or nodular thickening of the uterosacral ligaments which obliterate the cul-de-sac of the Pouch of Douglas. The third pattern is an extension of the second, with lesions extending from the lower part of the Pouch of Douglas into the rectovaginal septum. The therapeutic options for patients depend on the location and extent of disease and the relative proportion of active and fibrous endometriosis. Active endometriotic deposits are receptive to medical hormone treatment whilst scarring fibrous endometriosis, when symptomatic requires surgical lysis. Increasingly in clinical practice, this information is provided by detailed and high-resolution MR imaging of the pelvis.

LEIO MYO MAS (FIBRO IDS) O F THE UTERUS The role of imaging studies in women with fibroids is to: (a) confirm diagnosis of fibroids, (b) exclude other causes of uterine enlargement or pelvic masses such as adenomyosis, uterine malignancy and ovarian masses, (c) exclude renal obstruction due to fibroid uterus, (d) precisely determine number, size and location of fibroids. Conventional radiographs have a limited role in the diagnosis or management of uterine fibroids. Unless heavily calcified, fibroids are not depicted on radiographs. Very large fibroids result in a non-specific softtissue masses arising from the pelvis which may displace the bladder or loops of bowel. Computed tomography similarly has a limited role. Fibroids are usually indistinguishable from normal myometrium unless they are calcified or necrotic. Transvaginal ultrasound is the imaging modality of choice in the detection and confirmation of uterine fibroids. The most frequent US appearance is that of a concentric, solid, hypoechoic myometrial mass. However TVUS is very operator dependent and appreciation of the relationship between fibroids and remaining structures of the pelvis is limited. Its main role is to confirm the presence of suspected benign fibroids and exclude significant sub-mucosal fibroids. Detailed evaluation of sub-mucosal fibroids can be performed using instillation of saline into the endometrial cavity which clearly outlines sub-mucosal fibroids. Comparative studies have shown MRI has a better histological correlation than TVUS for detection and assessment of fibroid size, providing a better estimation of the overall fibroid burden.43 In addition, MRI can exclude and characterise other pelvic masses, detect adenomyosis and exclude renal obstruction in a single study. Hence, MRI is used for stratification of treatment options in fibroid disease. Magnetic resonance imaging has an important role in defining the anatomy of the uterus and ovaries, as well as planning myomectomy, selective surgical removal or planning selective fibroid therapies like uterine artery embolisation, radiofrequency ablation, HIFU, etc. With the emergence of these selective percutaneous ablation

procedures, such as cryotherapy and HIFU, MRI is used in pre-procedural planning, administering therapy by means of open MRI scanners and in follow-up of patients. Uterine artery embolisation (UAE) is now a well-established technique for treating fibroids and is suitable for the majority of women. The technique is clinically successful in the majority (80%–85%) of women following UAE, requiring no further treatment.44,45 Magnetic resonance imaging is routinely used to plan UAE and for post-procedural surveillance. Intravenous gadolinium is not usually necessary unless assessment of fibroid vascularity is required. Fibroids have an inconsistent appearance on MRI due to the different types of degenerative changes and variable enhancement patterns (Figs. 4.26 and 4.27). This often leads to myometrial masses being indistinguishable from malignant leiomyosarcomas (Fig. 4.28). The role of MRI in these myometrial masses is to confirm a benign fibroid but cannot reliably exclude malignant leiomyosarcomas although the latter is very rare. The appearances of uterine sarcomas are varied

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Fig. 4.26: Degenerating łbroid in pregnancy: Sagittal T2-weighted image showing a large fundal łbroid (arrowed) undergoing cystic degeneration in pregnancy. The łbroid retains low T2-signal intensity in the periphery (arrowheads) whilst centrally, high T2-signal intensity in keeping with cystic changes is demonstrated (asterix). The uterine pregnancy and foetus are shown (arrowheads).

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Section A | Introduction, Anatomy, Pre-op. Diagnosis and Management, Imaging, Skill Learning, Postop. Care with leiomyosarcomas being myometrial-based masses. They have poorly defined margins and contain multiple pockets of high T2 signal intensity which enhance following administration of intravenous gadolinium.46 Rapid or unexpected growth after menopause, raise the level of suspicion that the mass may be a sarcoma. Also, with advanced malignant lesions there may be evidence of local invasion. Should there be any uncertainty of the diagnosis after ultrasound and MR imaging, surgery is indicated.

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C o nc lusio n

Fig. 4.27: Benign degenerating łbroid: Sagittal T2-weighted image demonstrating a large anterior cervical łbroid. There is a heterogenous mottled T2-signal intensity throughout the łbroid. These were shown to be myxoid changes on histological specimen. These appearances are indistinguishable from a leiomyosarcoma.

Imaging plays an increasing role in the management of patients with gynaecological disorders. Each modality has unique properties that dictate its use in gynaecological pathology. Ultrasound is a real time, easily available, relatively inexpensive, non-radiation-based modality, making it suitable for first line use in young women or for repeated imaging. Transvaginal ultrasound provides very good anatomical detail of the uterus and ovaries. These properties make ultrasound the first line imaging technique for evaluation of the endometrium and adnexal pathology. Although CT is a radiation-based imaging modality, it remains widely used in staging, surveillance and treatment delivery of cancer. Its speed, ease of availability, excellent tissue characterisation and reproducibility are its main strengths. Magnetic resonance imaging provides exquisite anatomical information and has the best tissue characterisation properties for gynaecological imaging. Its role has expanded in all aspects of cancer management and it is likely to continue this growth with the emergence of functional MRI. Functional information provided by PET-CT is increasingly relevant to the detection of early recurrent disease and at staging gynaecological cancers as it improves the detection of distant disease.

Re fe re nc e s

Fig. 4.28: Leiomyosarcoma of the uterus: Sagittal T2-weighted image showing a large heterogeneous anterior myometrial mass (arrows). The mass is indistinguishable from a degenerating łbroid but a clinical history of rapid growth prompted surgical resection that conłrmed a leiomyosarcoma.

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1. Nagayama M, Watanabe Y, Okumura A, Amoh Y, Nakashita S, Dodo Y. Fast MR imaging in obstetrics. Radiographics. 2002; 22(3):563–80; discussion 580–2. 2. Sahdev A, Reznek RH. Tumour imaging in oncology. In: Price P, Sikora K, eds. Treatment of Cancer. 5th ed. London: Hodder Arnold Publication; 2008. 3. Shahid N, Ahluwalia A, Briggs S, Gupta S. An audit of patients investigated by Hysterosalpingo-Contrast-Sonography (HyCoSy) for infertility. J Obstet Gynaecol. 2005;25(3):275–8. 4. Hohmann J, Albrecht T, Hofmann CW, Wolf KJ. Ultrasonographic detection of focal liver lesions: increased sensitivity and speciicity with microbubble contrast agents. Eur J Radiol. 2003;46(2):147–59. 5. Chen J, Zhang Y, Liang B, Yang Z. he utility of difusion-weighted MR imaging in cervical cancer. Eur J Radiol. 2010;74(3):e101–6. 6. Namimoto T, Awai K, Nakaura T, Yanaga Y, Hirai T, Yamashita Y. Role of difusion-weighted imaging in the diagnosis of gynecological diseases. Eur Radiol. 2009;19(3):745–60.

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Liapi E, Kamel IR, Bluemke DA, Jacobs MA, Kim HS. Assessment of response of uterine ibroids and myometrium to embolization using difusion-weighted echoplanar MR imaging. J Comput Assist Tomogr. 2005;29(1):83–6. hrall MM, DeLoia JA, Gallion H, Avril N. Clinical use of combined positron emission tomography and computed tomography (FDG-PET/CT) in recurrent ovarian cancer. Gynecol Oncol. 2007;105(1):17–22. Siperstein AE, Berber E, Ballem N, Parikh RT. Survival ater radiofrequency ablation of colorectal liver metastases: 10-year experience. Ann Surg. 2007;246(4):559–65; discussion 565–7. Kinkel K, Hricak H, Lu Y, et al. US characterization of ovarian masses: a meta-analysis. Radiology. 2000;217:803–11. Buy JN, Ghossain MA, Sciot C, et al. Epithelial tumors of the ovary: CT indings and correlation with US. Radiology. 1991;178:811–8. Sohaib SA, Sahdev A, Van Trappen P, et al. Characterization of adnexal mass lesions on MR imaging. AJR. 2003;180: 1297–304. Spencer JA, Forstner R, Cunha TM, Kinkel K. ESUR guidelines for MR imaging of the sonographically indeterminate adnexal mass: an algorithmic approach. ESUR Female Imaging Sub-Committee. Eur Radiol. 2010;20(1):25–35. Coakley FV, Choi PH, Gougoutas CA, et al. Peritoneal metastases: detection with spiral CT in patients with ovarian cancer. Radiology. 2002;223:495–9. Forstner R, Hricak H, Occhipinti KA, et al. Ovarian cancer: staging with CT and MR imaging. Radiology. 1995;197: 619–26. Low RN, Sebrechts CP, Barone RM, Muller W. Difusion-weighted MRI of peritoneal tumors: comparison with conventional MRI and surgical and histopathologic indings—a feasibility study. AJR Am J Roentgenol. 2009;193(2):461–70. Cho SM, Ha HK, Byun JY, et al. Usefulness of FDG PET for assessment of early recurrent epithelial ovarian cancer. AJR. 2002;179:391–5. Nasu K, Abe W, Takai N, Tomonari K, Narahara H. Impact of positron emission tomography/computed tomography in the management of patients with epithelial ovarian carcinoma ater treatment. Arch Gynecol Obstet. 2010; [Epub ahead of print]. Smith-Bindman R, Kerlikowske K, Feldstein VA, et al. Endovaginal ultrasound to exclude endometrial cancer and other endometrial abnormalities. JAMA. 1998;280:1510–7. Gupta JK, Chien PF, Voit D, Clark TJ, Khan KS. Ultrasonographic endometrial thickness for diagnosing endometrial pathology in women with postmenopausal bleeding: a meta-analysis. Acta Obstet Gynecol Scand. 2002;81:799–816. Pecorelli S. Revised FIGO staging for carcinoma of the vulva, cervix, and endometrium. Int J Gynaecol Obstet. 2009;105(2):103–4 Fishman A, Altaras M, Bernheim J, Cohen I, Beyth Y, Tepper R. he value of transvaginal sonography in the preoperative assessment of myometrial invasion in high and low grade endometrial cancer and in comparison to frozen section in grade 1 disease. Eur J Gynaecol Oncol. 2000;21:128–30. Hardesty LA, Sumkin JH, Hakim C, Johns C, Nath M. he ability of helical CT to preoperatively stage endometrial carcinoma. AJR. 2001;176(3):603–6. Manfredi R, Mirk P, Maresca G, et al. Local-regional staging of endometrial carcinoma: role of MR imaging in surgical planning. Radiology. 2004;231(2):372–8.

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40.

41.

42.

Morrow CP, Bundy BN, Kumar RJ, et al. Relationship between surgical-pathological risk factors and outcome in clinical stages I and II carcinoma of the endometrium: a gynaecologic oncology group study. Gynaecol Oncol. 1991;40:55–6. Tozzi R, Malur S, Koehler C, Schneider A. Analysis of morbidity in patients with endometrial cancer: is there a commitment to ofer laparoscopy? Gynecol Oncol. 2005;97:4–9. Kitchener H, Swart AM, Qian Q, Amos C, Parmar MK. Eicacy of systematic pelvic lymphadenectomy in endometrial cancer (MRC ASTEC trial): a randomised study. Lancet. 2009;373:125–36. Saga T, Higashi T, Ishimori T, et al. Clinical value of FDG-PET in the follow up of post-operative patients with endometrial cancer. Ann Nucl Med. 2003;17(3):197–203. Subak LL, Hricak H, Powell CB, Azizi L, Stern JL. Cervical carcinoma: computed tomography and magnetic resonance imaging for preoperative staging. Obstet Gynecol. 1995;86:43–50. Bipat S, Glas AS, van der Velden J, Zwinderman AH, Bossuyt PM, Stoker J. Computed tomography and magnetic resonance imaging in staging of uterine cervical carcinoma: a systematic review. Gynecol Oncol. 2003;91(1):59–66. Mitchell DG, Snyder B, Coakley F, et al. Early invasive cervical cancer: tumor delineation by magnetic resonance imaging, computed tomography, and clinical examination, veriied by pathologic results, in the ACRIN 6651/GOG 183 Intergroup Study. J Clin Oncol. 2006;24(36):5687–94. Sahdev A, Sohaib SA, Wenaden AE, Shepherd JH, Reznek RH. he performance of magnetic resonance imaging in early cervical carcinoma: a long-term experience. Int J Gynecol Cancer. 2007;17(3):629–36. Sahdev A, Jones J, Shepherd JH, Reznek RH. MR imaging appearances of the female pelvis ater trachelectomy. Radiographics. 2005;25(1):41–52. Amit A, Beck D, Lowenstein L, et al. he role of hybrid PET/CT in the evaluation of patients with cervical cancer. Gynecol Oncol. 2006;100(1):65–9. Belhocine T, hille A, Fridman V, et al. Contribution of wholebody 18FDG PET imaging in the management of cervical cancer. Gynecol Oncol. 2002;87(1):90–7. Liu FY, Yen TC, Chen MY, et al. Detection of hematogenous bone metastasis in cervical cancer: 18F-luorodeoxyglucose-positron emission tomography versus computed tomography and magnetic resonance imaging. Cancer. 2009;115(23):5470–80. Saravelos SH, Cocksedge KA, Li TC. Prevalence and diagnosis of congenital uterine anomalies in women with reproductive failure: a critical appraisal. Hum Reprod Update. 2008;14(5):415–29. Wu MH, Hsu CC, Huang KE. Detection of congenital Mullerian duct anomalies using three-dimensional ultrasound. J Clin Ultrasound. 1997;25:487–92. Pellerito JS, McCarthy SM, Doyle MB, Glickman MG, DeCherney AH. Diagnosis of uterine anomalies: relative accuracy of MR imaging, endovaginal ultrasound, and hysterosalpingography. Radiology. 1992;183:795–800. Woodward PJ, Sohaey R, Mezzetti TP Jr. Endometriosis: radiologic-pathologic correlation. Radiographics. 2001;21(1): 193–216. Kataoka ML, Togashi K, Yamaoka T, et al. Posterior cul-de-sac obliteration associated with endometriosis: MR imaging evaluation. Radiology. 2005;234(3):815–23. Bazot M, Darai E, Hourani R, et al. Deep pelvic endometriosis: MR Imaging for diagnosis and prediction of extension of disease. Radiology. 2004;232:379–89.

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Levens E, Wesley R, Premkumar A, Blocker W, Nieman L. Magnetic resonance imaging and transvaginal ultrasound for determining ibroid burden: implications for research and clinical care. Amer J Obstet Gynaecol. 2009;200(5):537.e1–7. 44. Keeling AN, Reidy JF. Imaging and treatment of uterine ibroids, including the role of uterine artery embolisation. Imaging. 2007;19:374–84.

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Narayan A, Lee AS, Kuo GP, Powe N, Kim HS. Uterine artery embolization versus abdominal myomectomy: a long-term clinical outcome comparison. J Vasc Interv Radiol. 2010;21(7): 1011–7. 46. Sahdev A, Sohaib SA, Jacobs I, Shepherd JH, Oram DH, Reznek RH. MR imaging of uterine sarcomas. AJR Am J Roentgenol. 2001;177(6):1307–11.

Le a rning Ba sic Surg ic a l Skills

5

Christian Barnick, Caroline E. Everden

Intro d uc tio n With the introduction of the European Working Time Directive and subsequent loss of team-based working, the traditional apprenticeship system of training is disappearing. We find ourselves working with a wide range of colleagues, all of whom must be confident that we can equip ourselves well in theatre. The acquisition and demonstration of a sound skill base signals to your seniors a readiness to accept new surgical challenges—opportunity will invariably be given to those best prepared. This chapter aims to set out the basic skills a surgeon should have, and how we can best learn them.

Wha t to Le a rn? Surgeons should not only know the operation they are about to perform but also the team assembled and the equipment available. As surgeons, we are not soloists and should be able to communicate with our teams clearly and succinctly. How can we ask for an appropriate instrument if we do not know its name, or ask for assistance if we cannot describe the anatomy of the area?

rather than flexed. This enables an even pressure and predictable depth to be achieved. Transfer of scalpels between staff should be done in a kidney dish; or if they must be passed directly, with the handle proffered first.

SC ISSO RS (FIG . 5.1) Held with the thumb and ring fingers inserted no further than the distal phalanges, the index finger supports the instrument over the joint. Cuts should be made with the tip of the scissors, which should be under direct vision at all times to avoid inadvertent tissue damage. Scissors may be curved or straight; curved are usually reserved for tissue, while straight scissors are more normally used for sutures. The practised surgeon can use scissors in either hand, ambidexterity being a skill surgeons should try to acquire in order to improve efficiency in theatre. Some assistants may also ‘palm’ their scissors to keep them handy for cutting sutures. Removing their thumb from one ring, the scissors are rotated to be supported on only the ring finger, with the shaft held across the palm by the little finger.

NEEDLE HO LDERS (FIG . 5.2)

Instrum e nts To perform an operation safely we need to be able to see what we are doing. This involves choosing an appropriately sited and sized incision, dissecting tissue planes clearly, retracting and manipulating tissues in a safe manner and achieving haemostasis throughout the procedure. When handed and handling instruments the surgeon’s priority is safety for themselves, their patient and assistants; this is best achieved through correct handling, predictable economical movements and thoughtful transfer of instruments between staff.

SC A LPELS During skin incisions hold the scalpel as a dinner knife, with the index finger along the back. The finger should be clear of the tip by at least 3–5 cm and the palm should support the handle securely. Incisions should be made with the full length of the blade rather than the tip and the wrist should be firm

Held in the same way as scissors, the main movement should come from the wrist and forearm. A rotation at the wrist should provide enough energy to pass needle through tissue, if not the initial placement of the suture tip should be questioned. When returning a needle-holder to your scrub nurse first guard the needle. It is also good practice to announce the passing of all sharps—‘guarded needle back’, ‘unguarded needle in bowl’—especially with unfamiliar teams.

HA EMO STA TS (FIG . 5.3) Held as scissors or needle holders, the tip is used to grasp vessels, with the target vessel in direct vision the haemostat is applied and pressure increased by virtue of the ratchet lock. Manipulation to allow placement of sutures or application of diathermy should be minimal to avoid damage to the vessel. Removal should be possible with left or right hand, a skill that should again be practised. During removal it is important that the ratchet is released before the haemostat is pulled on to avoid tissue damage.

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Fig. 5.1: Scissors.

Fig. 5.2: Needle holders.

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Fig. 5.3: Haemostats.

C LA MPS (FIG 5.4)

RETRA C TO RS (FIG . 5.5)

These are heavier instruments than haemostats, used to grasp blocks of tissue that require division and ligation. Depending on the location and access clamps may be straight, curved or semicurved. As the tissue being divided often contains large blood vessels it is imperative that the clamp has a good grip of the contained tissue without causing damage that could cause bleeding prior to ligation. The tip of the clamp should also be considered—if toothed then it should be placed clear of any vessels. Removal of clamps should only be done at the specific request of the lead surgeon, as only they will know whether the suture is in place or knot ready to tighten. As with haemostats it is important that the ratchet lock is released prior to pulling away.

The safest surgery is done under direct vision and retractors should be used to achieve this. They allow visualisation of the target area but can also ensure that tissues are protected from damage. Depending on the area being operated on different retractors may be used. For vaginal work, a Sims’ or Langdon may be useful, for deeper pelvic work a self-retaining or ring retractor might be more appropriate. All of the above instruments come in many variations. When starting to operate, spend some time with the scrub nurse and familiarise yourself with the instruments that make up the minor, major and vaginal sets at your hospital. All sets come with a checklist that can be used to test your

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Fig. 5.5: Retractors

knowledge (once the scrub nurse has confirmed the count is correct).

SUTURES Sutures are used to hold wounds in apposition until healing can occur to a degree sufficient to support the tissues, also obliterating dead space and distributing tension evenly. This description should be held in mind when selecting the suture and technique appropriate to a wound.

Material Fig. 5.4: Clamps.

Sutures can be absorbable or non-absorbable, the former having a relatively predictable breakdown profile with gradually 63

Section A | Introduction, Anatomy, Pre-op. Diagnosis and Management, Imaging, Skill Learning, Postop. Care Table 5.1:

Suture composition and breakdown – data from Ethicon1

Absorbable synthetic sutures

5

Absorbable non-synthetic Non-absorbable

Suture

Material

Construction

Colour

Strength reduction prołle

Absorption prołle

Vicryl rapide

Polyglactin 910

Braided

Undyed

50% at 5 days 0% at 10–14 days

42 days

Vicryl

Polyglactin 910

Braided/ monołlament

Violet/ undyed

75% at 2 weeks 50% at 3 weeks 25% at 4 weeks

56–70 days

Monocryl

Poligecaprone 25

Monołlament

Violet/ undyed

Undyed Dyed 50–60% 60–70% 1 week 20–30% 30–40% 2 weeks

91–119 days

PDS II

Polydioxane

Monołlament

Violet/ undyed

4/0 3/0 60–80% 2 weeks 40–70% 3 weeks 35–60% 4 weeks

183–238 days

Surgical gut – chromic ‘cat-gut’

Beef serosa or sheep submucosa

Virtual monołlament

Brown/blue dyed

21–28 days

90 days

Prolene

Polypropylene

Monołlament

Blue/clear

Non-absorbable

Perma-hand silk

Silk

Braided

Black/white

Non-absorbable

reducing strength. The material of the suture determines the time to breakdown but also the degree of tissue reaction to the suture. The construction of the suture should also be considered—with monofilaments less likely to harbour infection than a braided suture, but braided sutures being more tolerant of handling and easier to securely knot (Table 5.1).

Needles Once the appropriate suture has been chosen we also have to consider how to introduce it to the tissue. The needle should have the smallest profile required for the suture, be stable and easy to grasp in the needle holder, remain sharp after several passes through tissue and cause minimal trauma to the tissue. Needles may be traumatic or atraumatic. Traumatic needles need to be threaded; atraumatic needles are swaged to the suture permanently or as a ‘pop-off ’ (separating with a sharp tug). Cutting

Used for penetration of thick/dense tissue Conventional – 3rd cutting edge on concave surface – ‘surface seeking’ Reverse – 3rd cutting edge on convex surface – ‘depth seeking’ Side-cutting – flat on top and bottom to reduce tissue injury

Taperpoint Stretches tissue as it passes instead of cutting. Used for easily penetrable tissue and to reduce the chance of fascial tearing. Blunt 64

Rounded blunt tip to dissect rather than cut. Used for friable tissue and also to reduce needle stick injuries.

Knot Tying and Suturing Tying a safe efficient knot allows the surgeon to sleep well at night. There are many techniques but all should aim to achieve the following: a small solid knot, tied with minimal thread handling and tensioned evenly. This will give good haemostasis, maintain tensile strength and avoid tissue damage. Techniques for tying single handed, double handed and instrumentally tied knots are shown in Figures 5.6, 5.7 and 5.8, respectively. Reef knot: The commonest knot used in surgery as it is secure and can be tied using one or both hands. Instrument tie: Useful when there is a short end that cannot be cleanly manipulated over a finger in order to tie a knot. Always try to manipulate the suture material at the end to avoid damage. Aberdeen knot (Fig. 5.9): Used to tie a loop and free end, such as is generated at the end of a continuous suture. Interrupted sutures: These should be placed equidistant from each other and the wound edge, distributing tension equally. When used to close long wounds the first suture should be placed in the middle and then further sutures placed halving these gaps – this ensures that wound closure is even and there isn’t an excess of tissue left at one end, resulting in an ugly ‘dog-ear’. Placed at right angles to the wound, the knot should be laid to one side (with the same side used for all sutures in a row). Mattress sutures: Placed vertically or horizontally, these are used to ensure eversion or inversion of a wound edge. Continuous sutures: One end of the suture is secured at the angle of a wound. The length is then used to provide a

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Fig. 5.6: Single handed variety of surgeon’s knot.

Fig. 5.7: Double handed variety of surgeon’s knot. This knot should be used for all major pedicles. It is easier to maintain appropriate tension between throws and to ensure that a true reef knot is tied rather than two half hitches (sliding knot).

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Fig. 5.8: Instrumental method of surgeon’s knot. This is essential for microsurgical procedures. Note the length of free suture material which is left after insertion of the suture and the direction in which it lies. The loop should be formed approximately three times the free length in order to achieve accurate placement of the throw. Efłcient knot tying depends upon correct positioning in the initial stages.

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(a)

(c)

(b)

(d)

Fig. 5.9a–d: Aberdeen casting off knot. Traction should only be applied to the lower (“afferent”) limb of the loop; this tightens the throw without the risk of friction damage.

Learning Basic Surgical Skills ‘running’ stitch. The strength of this type of suture is dependent on tension being maintained evenly throughout, usually via an assistant ‘following’ and holding the suture material taut. Sub-cuticular sutures: A variation of a continuous suture, here the material stays in the sub-cuticular layer, with sutures placed to ensure direct apposition of the wound edges.

Ele c tro surg e ry: Use a nd Sa fe ty Adequate haemostasis is a constant concern for the surgeon. As surgeons of old would use cautery through the application of heated tools, the modern surgeon relies on electricity. The application of voltage across a material produces an electrical field that causes a flow of charge carriers, electrical current. As current flows, the resistance of the tissue converts some of the original electrical energy into heat energy.

BIPO LA R A pair of similar sized electrodes are used – usually a pair of forceps. One prong is attached to one pole of the AC generator, while the other is connected to the other pole of the generator. High-frequency electrical current flows from one to the other heating the tissue held between.

MO NO PO LA R The surgeon uses a single electrode to deliver the energy, which returns to the generator via a larger return electrode attached to the patient. Current density and therefore the heating potential drops rapidly with increasing distance from the active electrode so heating only occurs in a localised area. Typically electrosurgical equipment operates in the radiofrequency range (200 kHz–3.3 MHz). This minimises muscle and neuronal stimulation. Electrosurgery can cut, coagulate or fulgurate tissue. Cutting The electrode touches the tissue and sufficient (yellow pedal) energy density is applied to explosively vapourise the water content. The vapour cannot normally conduct current and therefore the effect is self-limiting. Cutting is normally performed with a continuous high current and low-voltage sine waveform Coagulation The sine waveform is interrupted, and therefore (blue pedal) voltage in periods of flow increases, generating a greater heating and coagulation effect. Protein denaturation and fibrinous tissue bonding is triggered, sufficient to seal small and medium diameter blood vessels Fulguration The electrode is held away from the tissue. (blue pedal) An arc is generated and as the current is spread over a wider area a more superficial depth of heating is achieved. This is typically used on surface lesions rather than individual vessels.

SA FETY Safe return of current (completion of circuit) is essential to avoid inadvertent damage to the patient. Potential pitfalls are outlined below. Electrocautery will also generate smoke; there are concerns that this is potentially carcinogenic and so it should be sucked away from the field as efficiently as possible. Grounding pad Insufficient contact with the grounding pad wrongly placed can lead to third degree burns in areas where the contact was poor, or in other areas of the patient in contact with metal objects that provide an alternative grounding pathway. Pads should always be placed as closely to the operating site as is practical, typically on the outer aspect of the thigh in gynaecology surgery. Metal-work not If the patient has any metallic implants, such as recognised a hip replacement, the grounding pad should be placed on the opposite side of the body from the metal to prevent current passing through selectively on the way to ground. Unintentional The electrode should always be firmly placed thermal damage on tissue, with the whole electrode under direct vision to prevent inadvertent damage. An unwanted current path can also develop if another conducting instrument is present and in contact with the electrode, leading to damage distant to the electrode. The electrode may also retain some heat so should be handled with care. When not in use the electrode should be kept in an insulated holder. Insulation failure If there is a break in the insulation of the electrode then thermal effect will occur wherever current can flow.

5

Ho w Do We Le a rn? Learning and education have long been fertile areas for research. When looking at educational theory it is important to use it as a lens through which to perceive our own learning behaviours and as a catalyst for increasing their efficiency. We first have to prepare to learn. Hopefully our years of study at Medical School will have equipped us with an ability to assimilate facts and exposed us to a surgical environment for long enough that we have a basic familiarity to build on. Armed with that familiarity it becomes easier to see the usefulness of the abstract skills we have to acquire. Considering the application of each skill allows us to place it within a growing network of knowledge that will become increasingly interconnected. Once prepared, we then start to acquire skills through several methods: Changes in the way we behave Respondent conditioning: This is the association of a behaviour with a stimulus. Pavlov trained his dogs to salivate to a number of non-food stimuli because they

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68

were all initially presented in conjunction with food. This requires repetition but no analysis. If a surgeon always asks for a certain suture when they are concerned about bleeding, the anaesthetist eventually starts to check the patient’s blood pressure in response to overhearing a request for that suture type. Operant conditioning: This requires a trigger and response – an operant and reinforcement. B. F. Skinner developed this theory, stating that rewards speed up learning if they come directly after the behaviour, but the effect lasts longer if rewards are only intermittent. The trainee places a suture well (operant) and is sometimes allowed to start the next procedure (reinforcement). Changes in the way we think Using the theories of Jean Piaget,2 who worked primarily on child learning, we look at assimilation and accommodation— interpreting new information in view of pre-existing knowledge and concepts, then revision of pre-existing concepts in light of new information. This is the way that the self-directed learner works. With changes in training encouraging more formal education and instruction we find Jerome Bruner’s theory more relevant that guidance in the form of ‘instructional scaffolding’ can speed and heighten the acquisition of knowledge.3 We will look at an incision site in view of our pre-existing knowledge of the paths of nerves in the area (assimilation), alter our 2D concept of anatomical relations as we operate more (accomodation), and progress through this more quickly if our lead surgeon explains the reasoning behind his approach while quizzing our knowledge (instructional scaffolding). Changes in our procedural ability and psychomotor skills A common model for skill acquisition is that outlined by Dreyfus & Dreyfus.4 Building on work initially funded in part by the US Air Force they developed a five-stage model of the mental activities involved in directed skill acquisition. Novice Rigid adherence to taught rules or plans Little situational perception No discretionary judgement Advanced Guidelines for action based on attributes or beginner aspects Limited situational awareness All attributes and aspects treated separately and equally Competent Conscious deliberate planning Standardised routine for procedures Proficient Holistic perception of situations Can perceive and respond to deviations from an established pattern Able to perceive the important aspects of a situation Expert No longer relies on guidelines or rules Intuitive grasp of situations Analytical approach only used for novel situations The aim of training is to accelerate progression up this scale, while ensuring that patients do not suffer at the hands of the trainee. Taking the example of wound closure:

Knows the steps involved in placing a sub-cuticular suture. Able to close skin when prompted with a sub-cuticular suture. Aware that skin is normally closed with a sub-cuticular suture and can perform this from start to finish without prompting. Able to see that a wound may benefit from an alternative method of closure and select a better alternative after consideration Automatically alters technique to the situation without needing to analyse, based not only on wound characteristics but also patient need. We aim to move from ‘controlled processing’ to ‘automatic processing’.5 This involves the transition from complete immersion in a step-by-step process that demands our full attention, to being able to complete a set of tasks automatically while also being aware of the wider situation and having the capacity to plan our next step. We have all been in situations where ourselves or others were so focused on the correct application of a suture or device that other considerations, such as blood loss or correct use of assistants was forgotten.

Ho w to Le a rn TRA INING PRO G RA MMES Modernising Medical Careers (www.mmc.nhs.uk) has changed post-graduate medical training in the UK completely. Driven by a need to reflect the changing environment in which care is delivered, MMC acknowledged the importance of effective teams and multidisciplinary working, while acknowledging that service provision and personal development had to be balanced. The process established key principles for any training programme (see box). Key Principles and Standards for Postgraduate Medical Education Training Programmes6 High-quality patient care depends on sound education and training. Programmes must follow the guidance set out in the General Medical Council’s guidance ‘Good Medical Practice’. Programmes must have a defined curriculum to enable trainees to achieve that Programme’s learning outcomes. Programmes must be sensitive to the trainee’s individual needs. Selection for entry to Programmes must be fair. Programmes must promote equality and value diversity within the profession. Programmes must have explicit quality assurance processes. Those who have responsibilities for training must develop the skills, attitudes and practices of a competent teacher and ensure that trainees are properly supervised. Programmes must be resourced to achieve the Programme’s learning outcomes. Programmes must take place within the regulatory framework laid out in UK law.

Learning Basic Surgical Skills This led to the development of a new training scheme in the UK. After 2 years in a Foundation programme there are 7 years of speciality training; ST1-2 at an SHO level, then ST3-5 to develop core skills, leading to ST6-7 where advanced training in specific areas is pursued, after which the Certificate of Completion of Training is awarded. The key principle which underpins the new approach to Speciality training is a seamless single programme where basic and higher competencies are acquired progressively. In US, medical students apply directly to a Residency programme, and if accepted as a categorical trainee will proceed through the years of training in much the same way as in the UK system.7

SIMULA TIO N IN TRA INING ‘Simulation is a technique – not a technology – to replace or amplify real experiences with guided experiences that evoke or replicate substantial aspects of the real world in a fully interactive manner.’ —Professor David M Gaba, Stanford University

Simulation training covers everything from a low-fidelity simulation of skin for suturing practice to a virtual reality highfidelity interactive programme for practising laparoscopy.

Why Use Simulation? The Chief Medical Officers report in 2008 called for simulation to be more fully integrated into the health service as it had demonstrated an ability to train surgeons in a way that reduced error and improved technical accuracy. Simulator training in laparoscopic salpingectomy increased proficiency levels and halved operating time compared to traditional teaching methods.8 Simulation appears to achieve this through the theory of ‘deliberate practice’. Proposed by Ericsson,9 the learner focuses

Table 5.2:

on individual tasks chosen by a teacher. Repeated practice accompanied by immediate feedback and teaching leads to the attainment of expertise in a predictable way. This situation is hard to achieve in the operating theatre as it requires the repetition of tasks in quick succession. The Dreyfuss model of skill acquisition shows that simulation should allow us to achieve competence with our basic skills, thereby ensuring we can make the most of valuable theatre time. Simulators allow slow, deliberate, repetitive practice in a safe and non-threatening environment where mistakes can be recognised and rectified without impact on patients.

5

Types of Available Simulator Training Tasks presented in a concrete everyday manner are easier to grasp and solve. Simulators attempt to reproduce, to a greater or lesser extent, the clinical situation. They can be divided into low and high fidelity (Table 5.2). Low fidelity: Reproduce aspects of a task using some of the usual equipment. High fidelity: Reproduce a clinical situation using realistic materials and equipment. Both box trainers and virtual reality simulators allow the trainee to develop one of the most important skills in laparoscopy – effective navigation of a 3D environment while guided by 2D visual feedback. Specific tasks, such as camera and instrument handling, hand-eye coordination and precise movement and manipulation10 have been shown to improve with targeted box trainer use, while virtual reality simulators have improved blood loss and operating time in simulated procedures.11 The trainee should use simulation technology only where there is access to feedback – either directly from the software or via a trainer being present. All the studies showing positive effects on training have been based around specific tasks. Goal setting and feedback improve skill levels in the simulated environment and in the theatre.12,13

Types of simulators

Type of simulator Description and examples

Assessment

Advantages

Disadvantages

Bench models – low łdelity

Observation by supervisor, comparison to completed models

Cheap

Requires presence of a trainer

Mass produced and available from a variety of providers

Disparity between model and reality

Portable

Usually limited to one task

Endoscopy trainer using a closed box with insertion points for instruments and camera

Observation by supervisor

Can be purchased or improvised from existing equipment

Better with presence of a trainer

Computer-based system where an interface based on real surgical instruments feeds data to a life-like display

Direct from software using ideal parameters for speciłc tasks

Static, usually single task, models. Suturing practice – perineum models

Box trainers – low łdelity

Virtual reality simulators – high łdelity

Comparison to video of ‘ideal’ technique

Can use real surgical instruments Allows trainee to practice without direct supervision Multifunctional – can be used for single tasks or whole procedures

Sensory feedback different to real tissue Expensive equipment Not all systems have tactile feedback Usually static due to cost and size

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Section A | Introduction, Anatomy, Pre-op. Diagnosis and Management, Imaging, Skill Learning, Postop. Care

USING A SSESSMENT TO DRIVE LEA RNING To proceed through the new speciality training programmes requires each trainee to prove their acquisition and mastery of skills. While this may be viewed by many as a time-consuming paper exercise, it can be harnessed to improve learning. Feedback allows us to improve our techniques, and formal assessment can provide structure to that process.

5 Case Logs Measuring activity and hours spent in the operating theatre is a traditional method of assessing a trainee, undermined by recent reductions in working hours. We would suggest an addition to this system. Start to develop your own ‘ideal’ method for an operation. Within this text you will find guidance on how to perform certain procedures. These are safe and effective methods that have been honed overtime. From theoretical texts, such as this, build knowledge of the steps required. Master the basic skills that will allow you to be an efficient assistant, then watch your seniors. Take the best parts of their techniques and add them to your own, building not only a log of cases but also the best surgical methods.

OSATS Objective Structured Assessment of Technical Skills (OSATS) are forms used as a framework for assessing a procedure performed by a trainee. They have been validated14 and adopted widely. By breaking tasks into acquirable competencies they allow tracking of skill development overtime.

Educational Resources No matter which of these methods you utilise, it is important that time is directed well. Feedback is essential – only those more competent than ourselves can point out the extraneous step or awkward movements that would otherwise become barriers to efficiency.

www.winkingskull.com Contains detailed anatomical drawings and radiological imaging. www.google.co.uk Not a resource in itself, but a portal to numerous instructions in how to construct your own box trainer for practising laparoscopic skills, or tissue simulations for suturing practice. www.youtube.com and www.medicalvideos.us Not peerreviewed but a source for many suturing technique videos, as well as footage of operative procedures and anatomy demonstrations. Use with caution.

C O URSES

Basic Practical Skills With a curriculum set by the RCOG, the Basic Practical Skills course covers a wide range of skills. It is an essential requirement for transition to ST3 level. Details of times and locations can be found at http://www.rcog.org.uk/event. Skills covered include the following: Principles of safe and effective surgery

Handling instruments

Knot tying

Suturing

Handling tissues

Principles of haemostasis and dissection

Principles of electrosurgery

Principles of gynaecological examination

Anatomy of pelvic floor

Endoscopic equipment

Principles of safe hysteroscopy

Principles of safe laparoscopic entry

Episiotomy repair

D&C evacuation of uterus

Management of normal and breech delivery

Fetal blood sampling

Caesarean section

Ventouse and forceps delivery

Management of shoulder dystocia

Management of massive obstetric haemorrhage

Surgical documentation

WEBSITES www.stratog.net Available as online access or a DVD, StratOG provides a wide theoretical knowledge based on UK guidelines and training requirements. Regular evaluation of knowledge via MCQ style questions encourages learning. www.anatomy.tv A subscription service (free for Athens users) that provides interactive 3D models of the human body, with many specific gynaecological sections. www.laparoscopy.com An American-based website with pictures and videos of laparoscopic procedures. www.surgicalskills.net This covers basic techniques, such as knot tying and suturing, as well as general information on surgical instruments, consent, etc. Most content is accessed with a subscription. 70

C ha lle ng e s to Le a rning We cannot ignore the fact that economic pressures on healthcare mean that all provision must be cost effective. Private care providers have no obligation or incentive to provide training but will be removing the straightforward cases from the NHS and therefore the trainees view. Not all hospitals will be able to provide all services. The Royal College of Obstetricians and Gynaecologists produced a report that considered how future workforce considerations would impact on training.15 Trainees will have to harness the opportunities offered where they are employed and increasingly may have to consider their educational needs when considering their next placement. We may also have to cope more often with

Learning Basic Surgical Skills the challenges of working across sites. When designing rotations within training programmes it will be up to the trainees to push for fair exposure to all areas. These changes may make formal trainees seem an expensive luxury for trusts to support, although this short-term view could lead to a future shortage in appropriately skilled consultants.

C o nc lusio n The move from a consultant-led to consultant-delivered model of care has reduced the volume of operating available to junior doctors, but it also gives us an opportunity to see the different techniques and approaches employed by our seniors. The best surgeons never stop learning and their techniques will change overtime to take advantage of new technology and advances in knowledge.

8.

9. 10.

11.

12.

13.

14.

Re fe re nc e s 1. 2. 3. 4.

5. 6. 7.

Ethicon E-catalogue. Available at: http://www.ecatalog.ethicon. com. Jean Piaget. he Psychology of Intelligence. Routledge Classics; 2001. Jerome Bruner. he Process of Education. 25th ed. Harvard University Press; 1991. Dreyfus HL, Dreyfus SE. Mind Over Machine: he Power of Human Intuition and Expertise in the Era of the Computer. Oxford: Basil Blackwell; 1986. Shifren R, Schneider W. Controlled and automatic human information processing. Psychol Rev. 1977;84:161. http://www.mmc.nhs.uk/. Tavakkolizaden A, Zinner MJ, Ashley SW. US Surgical Training: A contemporary review. Ann R Coll Surg Engl (Suppl). 2004;86:52–5.

15.

Larsen CR, Soerensen JL, Grantcharov TP, et al. Efect of virtual reality training on laparoscopic surgery: a randomised controlled trial. BMJ. 2009;338:b1802. Ericcson KA, Prielvla MJ, Cokely ET. he Making of an Expert. Harvard Business Review, 2007. Clevin L, Grantcharov T. Does box model training improve surgical dexterity and economy of movement during virtual reality laparoscopy? A randomised trial. Acta Obstet Gynaecol. 2008;87:99–103. Aggarwal R, Tully A, Grantcharov T, et al. Virtual reality simulation training can improve technical skills during laparoscopic salpingectomy for ectopic pregnancy. BJOG. 2006;113: 1382–7. Gauger PG, Hauge LS, Andreatta PB, et al. Laparoscopic simulation training with proiciency targets improves practice and performance of novice surgeons. Am J Surg. 2010;199(1):72–80. Hyltander A, Liljegren E, Rhodin PH, Lönroth H. he transfer of basic skills learned in the laparoscopy simulator to the operating room. Surg Endosc. 2002;16:1324–8. Martin JA, Regehr G, Reznick R, et al. Objective structured assessment of technical skill (OSATS) for surgical residents. Brit J Surg. 1997;84:273–8. Royal College of Obstetricians and Gynaecologists. he Future Workforce in Obstetrics and Gynaecology, England and Wales. Full Report. London: RCOG Press; 2009.

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Furthe r Re a d ing 1.

Safer Medical Practice: Machines, Manikins and Polo Mints. 150 years of the Annual Report of the Chief Medical Oicer: On the state of public health 2008. 2. Ericcson KA. he acquisition of expert performance: an introduction to some of the issues. In: he road to excellence: the acquisition of expert performance in the arts and sciences, sports and games. Mahwah, NJ: Lawrence Erlbaum Associates, 1996.

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Po sto p e ra tive C a re a nd Pre ve ntio n o f C o m p lic a tio ns

6

Claire Mellon, Emma Kirk

In recent times there have been changes to the pre- and postoperative care of the gynaecological surgical patient to reflect changes in surgical practice. Endoscopic procedures are commonly performed and patients have a much shorter stay in hospital. Many procedures are performed as day cases. As a consequence, patients are often only admitted a few hours pre-operatively whether they are day cases or planned inpatient admissions. Clear protocols for patient selection are therefore extremely important. It is also important to have clear protocols and pathways for the management of these women postoperatively and in order to plan discharge. The early recognition of any postoperative complication is of great importance, both in order to institute prompt corrective treatment and to reduce the possibility of patients needing readmission following an early discharge.

Table 6.1:

Levels of postoperative care

Level of Care 0

Patients whose needs can be met through normal ward care in an acute hospital

1

Patients at risk of their condition deteriorating, or those recently relocated from higher levels of care, whose needs can be met on an acute ward with additional advice and support from the critical care team

2

Patients requiring more detailed observation or intervention including support for a single failing organ system or postoperative care and those ‘stepping down’ from higher levels of care

3

Patients requiring advanced respiratory support alone or basic respiratory support together with support of at least two organ systems. This level includes all complex patients requiring support for multi-organ failure.

Im m e d ia te Po sto p e ra tive C a re At the end of a surgical procedure, it is the role of the anaesthetist to determine when the patient is fit to be removed from the operating table. If the procedure has been performed under general anaesthesia, this will usually require reversal of muscle blockade and the re-establishment of spontaneous respiration. The patient will then be transferred to a recovery area within the theatre suite until consciousness has returned. The following parameters are closely monitored: pulse rate, blood pressure, respiratory rate, temperature, peripheral oxygen saturation, urine output, level of consciousness and pain score. Careful monitoring of vital signs and the use of an early warning score such as the modified early warning score (MEWS) during the recovery period is essential.1,2 In the first hour following surgery, these observations may be monitored every 15 minutes, reducing to every 30 minutes for the next 2 hours and then hourly. Depending on the clinical situation, other forms of monitoring may also be required, such as central venous pressure (CVP), arterial blood pressure, arterial blood gases, electrocardiogram (ECG), hourly urine output and drainage from wounds. The intensity of monitoring required will determine to what level care the patient is transferred. Levels of care range from a normal surgical ward (levels 0 and 1) to intensive care (level 3) (Table 6.1). Most complications that arise in the initial postoperative period are of an anaesthetic nature, resulting in respiratory or

cardiac compromise. However, some surgical complications may arise in this immediate recovery phase, which is why it is essential to produce comprehensive operative notes detailing any intra-operative complications and giving a clear postoperative management plan to hand over to the recovery staff.

A NA LG ESIA Postoperative patients require effective pain relief because it leads to a smoother postoperative course and has important physiological benefits. The site of the surgery has a profound effect on the degree of pain experienced and the consequent physical limitations. Any abdominal procedure may affect the ability to cough and clear secretions from the lung, and this may lead to a chest infection. Prolonged pain may also reduce physical activity and lead to venous stasis resulting in an increased risk of venous thromboembolism (VTE). There can also be effects on gut and bladder function, with the development of postoperative ileus, nausea, vomiting or urinary retention. The aim of postoperative pain management is not only to minimise patient suffering but to also reduce morbidity and facilitate rapid recovery and early discharge from hospital. Postoperative management should be step-wise. The World Health Organisation Analgesic Ladder (Fig. 6.1) was introduced to improve pain control in patients with cancer, but is now universally employed for the management of pain relief.

Section A | Introduction, Anatomy, Pre-op. Diagnosis and Management, Imaging, Skill Learning, Postop. Care

6

Paracetamol and NSAIDs

Strong opioids by injection, local anaesthesia

Add local anaesthetic and weak opioids

Oral opioids

Add strong opioids

Paracetamol and NSAIDs

Fig. 6.1: WHO analgesic ladder.

Fig. 6.2: WFSA analgesic ladder.

Management starts with simple peripherally acting drugs such as aspirin, paracetamol and non-steroidal anti-inflammatory drugs (NSAIDs). If pain control is not achieved, the second part of the ladder is to introduce weak opioid drugs such as codeine. If this is still ineffective, the final rung of the ladder is to introduce strong opioid drugs such as morphine. The World Federation of Societies of Anaesthesiologists (WFSA) has developed another ladder for guidance of postoperative pain management (Fig. 6.2).3 Initially, when the pain is expected to be severe, strong analgesics in combination with local anaesthetic blocks are used. These will usually be administered avoiding the oral route. As postoperative pain decreases with time, the need for drugs to be given by injection should cease and the oral route can be used. This will initially be with paracetamol, NSAIDs and weak opioids. The final step will be for the pain to be controlled with just paracetamol and/or NSAIDs. The choice of analgesia will depend on the site and extent of surgery (Table 6.2). Infiltration of a wound with a long-acting local anaesthetic can provide effective analgesia for many hours. If a strong opioid is needed, this can be administered via a patient-controlled analgesia (PCA) pump. It is known that patients’ requirements for opioids vary considerably and so administration via a PCA allows a patient to titrate the dose to their own requirements, hopefully minimising side effects. Excessive pain in the early hours after an operation, or apparent failure of analgesia, may be an early sign of a serious postoperative complication such as intra-abdominal bleeding or a perforated viscus, particularly if it is associated with deterioration in vital signs or excessive restlessness. Early surgical review is mandatory in such circumstances. Table 6.2: Analgesic options depending on severity of surgery and pain Mild pain

Moderate pain

e.g. laparoscopy e.g. hysterectomy hysteroscopy

Severe pain e.g. pelvic exenteration radical cancer surgery 1. Paracetamol and wound inłltration with local anaesthetic 2. NSAIDs 3. Epidural or PCA

1. Paracetamol and wound inłltration with local anaesthetic 2. NSAIDs 3. PCA 1. Paracetamol and wound inłltration with local anaesthetic 2. NSAIDs 3. Weak oral opioid, if necessary

74

O XYG EN There is little evidence to suggest the routine use of oxygen in the postoperative patient, but some studies have suggested supplemental oxygen reduces the incidence of wound infection. Hypoxaemia is common after surgery due to impaired gas exchange and ventilatory control following a general anaesthetic. Supplemental oxygen should only be used routinely in those at high risk of developing complications or who have oxygen saturations less than 92%. Those at increased risk of developing complications who may need prolonged monitoring and oxygen therapy include the obese, those with acute or chronic pulmonary disease, and those requiring sedative drugs or systemic opiates in the postoperative period.

TEMPERA TURE A postoperative patient is at risk of both hypothermia and pyrexia in the immediate postoperative period. Hypothermia may occur during surgery due to anaesthetic-impaired thermoregulation, open body cavities, the administration of unwarmed intravenous fluids and a cold-operating environment. It may also be a sign of sepsis in the acutely unwell. Active warming is appropriate for patients who are hypothermic. Forced air warming, used both intra-operatively and postoperatively to maintain a normal body temperature has been shown to be associated with fewer cardiac events in the postoperative period.

FLUID BA LA NC E In the postoperative period, patients are vulnerable to fluid and electrolyte imbalance due to many factors including intraoperative blood loss, fasting for long periods, pre-operative bowel preparation and exposure during surgery. It is therefore important to accurately measure the patient’s fluid balance in the recovery period. This should include recordings of the output of drains as well as of urine and vomit, and the measurement of fluid intake (oral and intravenous). The surgical wound and wound drainage sites should also be inspected regularly for excessive loss. The standard principles of fluid balance in the postoperative patient are to correct any pre-existing deficit, to supply basal needs, to replace any unusual losses (e.g. due to surgical drains and pyrexia) and to use the oral route whenever possible.4 The basal requirements of a healthy adult are approximately 30 mL/kg/day of water, 1.0–1.4 mmol/kg/day of sodium and 0.7–0.9 mmol/kg/day of potassium.

Postoperative Care and Prevention of Complications Those with large peri-operative fluid losses are most at risk of fluid and electrolyte imbalance within the postoperative period, as are the elderly, those with pre-existing cardiovascular, cerebrovascular or renal disease, and those that have suffered acute myocardial ischaemia or infarction in the peri-operative period. All patients should be monitored for hypotension, tachycardia, oliguria, signs of fluid overload (e.g. pulmonary oedema) and for more subtle signs such as confusion or tachypnoea. Oliguria is defined as a urine output of less than 0.5 mL/kg/hour for two consecutive hours. Hypotension, tachycardia, oliguria, confusion and tachypnoea may all be signs of hypovolaemia. These may also be signs of sepsis or a primary cardiac problem, but in a postoperative patient it is vital to first consider blood loss as a possible cause.

C A THETERS Urinary catheterisation is commonly performed prior to gynaecological surgical procedures for a variety of reasons. An ‘in and out’ catheter may be inserted just to empty the bladder for the start of the operation, or an indwelling catheter may be used to minimise trauma to the bladder during surgery and to monitor urine output intra- and postoperatively. A Foley catheter may also be left in if spontaneous voiding is likely to be difficult in situations such as the use of vaginal pack, where epidural anaesthesia has been used or if the patient is likely to be immobile.5 An indwelling catheter is usually left in to allow drainage of the bladder until the patient is mobile and this is usually less than 24 hours. If the catheter is left in for longer than 72 hours, the risk of infection rises from 60 mins when operating in the pelvis • Acute admission with inŃammatory or intra-abdominal condition • Expected signiłcant reduction in mobility • Active cancer or cancer treatment

6

• Age >60 years

be continued to 28 days postoperatively for patients who have had major cancer surgery in the abdomen or pelvis. It is important to reassess the patients’ risks of bleeding and VTE within 24 hours of admission and whenever the clinical situation changes, to ensure the current methods of VTE prophylaxis are suitable and that there are no adverse events resulting from its use. Most hospitals have a VTE policy and protocol based on NICE or other national guidelines.6 (See Chapter 3)

• Critical care admission • Dehydration • Known thrombophilia • Obesity (BMI >30 kg/m2) • One or more signiłcant co-morbidity, e.g. cardiac disease, respiratory pathology, inŃammatory condition. • Personal history or łrst degree relative with history of VTE • Use of hormone replacement therapy • Use of oestrogen containing contraceptive therapy • Varicose veins • Pregnancy or delivery within last 6 weeks

76

risk factors (such as age, obesity and concomitant conditions) (Table 6.3). The positioning of the patient on the operating table is also important. Lithotomy position is known to decrease venous blood flow in the lower limbs and increase the risk of VTE. The semi-lithotomy ‘ski’ position seems to confer some benefit by adding the effect of gravity to venous return without the inhibitory effect of knee flexion in the standard lithotomy position. In order to reduce the risk of VTE, women should be advised to stop oestrogen-containing contraceptives or hormone replacement therapy 4 weeks before elective major surgery. The risks and benefits of stopping pre-existing established antiplatelet therapy 1 week before surgery should also be assessed. Regional anaesthesia carries a lower risk of VTE than general anaesthesia, so should be considered in at risk patients. However, if regional anaesthesia is used, the timing of pharmacological VTE prophylaxis should be planned to minimise the risk of epidural haematoma. Mechanical VTE prophylaxis should be started in all gynaecological surgical patients on admission. This may be in the form of anti-embolism stockings (thigh or knee-length), foot impulse devices or intermittent pneumatic compression devices. These should be continued until the patient no longer has any significantly reduced mobility. Pharmacological VTE prophylaxis should also be prescribed for patients with a low risk of major bleeding, taking into account individual patient factors. The type of pharmacological VTE prophylaxis used will depend on local policies and those individual patient factors, but will include: low molecular weight heparin (LMWH), unfractionated heparin and fondaparinux sodium heparin (LMWH). Pharmacological VTE prophylaxis should be continued until the patient no longer has significantly reduced mobility, generally 5–7 days. However, it may need to

PREVENTIO N O F INFEC TIO N The gynaecological surgical patient may be affected by infection at number of different sites, the most important of which are chest, wound, operative site (i.e. abdomen or pelvis) and the urinary tract. There are number of factors that increase the risk of postoperative infection, see Table 6.4. Surgical site infection is thought to occur in at least 5% of patients undergoing a surgical procedure. Most are caused by contamination of an incision with microorganisms from the patient’s own skin, intestinal or respiratory system. A number of measures can be taken to reduce the risk of infection. Hair removal should not be used routinely to reduce the risk of surgical site infection. If hair does have to be removed prior to surgery, razors should not be used as they increase the risk of infection. Hair should be removed on the day of surgery using electric clippers with a single-use head. Before incision the skin at the surgical site should be cleansed using an antiseptic (aqueous or alcohol-based) preparation, povidone-iodine or chlorhexidine solution being most suitable. The surgical incision should also be covered with an appropriate occlusive dressing at the end of the operation.7 Some consideration should also be given to the use of antibiotic prophylaxis. However, antibiotics should only be used for prophylaxis where evidence of benefit exists (Table 6.5). The most common site of postoperative infection is the urinary tract. The incidence of urinary tract infection is not

Table 6.4:

Factors increasing the risk of postoperative infection

• Complicated surgery • Prolonged operation time • Emergency surgery • Prolonged postoperative stay • Obesity (BMI >30 kg/m2) • Coexisting infections at other sites • Hypothermia • Blood transfusion • Diabetes mellitus • Poor nutritional state • Increased age • Use of invasive procedures, e.g. urinary catheter and drains • Patients receiving chemotherapy, radiotherapy, steroids and immunosuppressants

Postoperative Care and Prevention of Complications Table 6.5: Recommendations for antibiotic prophylaxis in gynaecological operations Operation

Antibiotic prophylaxis recommendation

Abdominal hysterectomy

Recommended*

Vaginal hysterectomy

Recommended*

Caesarean section

Highly recommended**

Perineal tear

Recommended* for third and fourth degree tears

Termination

Highly recommended**

Surgical evacuation of miscarriage

Not recommended***

*Recommended – decreased short-term morbidity. **Highly recommended – unequivocally reduces major morbidity. ***Not recommended – no clinically proven benełt.

changed by the use of prophylactic antibiotics and is mostly associated with peri-operative catheterisation. In short procedures, such as a hysteroscopy or diagnostic laparoscopy, catheterisation can be avoided by encouraging patients to void pre-operatively. When an indwelling catheter has been used, it can usually be removed 12–24 hours post operatively, unless mobility is restricted. When the bladder may have been traumatised, for example in dissection from a Caesarean section scar at hysterectomy, it may be advisable to leave the catheter in longer. Septicaemia is not common in gynaecological patients, but is more prevalent in high-risk groups such as the immunocompromised, the elderly and patients who have had radical cancer surgery. Patients with septicaemia are likely to deteriorate very rapidly, and rapid response to identify organisms and commencement of appropriate antibiotics is essential. Transfer to a Critical Care Unit may be required, and involvement of a microbiologist can be life saving. The use of early warning charts are invaluable in alerting staff to the development of severe sepsis.

EA TING A ND DRINKING Formerly, patients undergoing major abdominal gynaecological surgery were denied food and fluids until the return of bowel sounds because of the fear of paralytic ileus and vomiting with subsequent aspiration pneumonia and wound dehiscence. A number of studies have evaluated early versus delayed initiation of oral intake of food and fluids. These have shown that early commencement of oral fluids and food is associated with a higher risk of nausea but a reduced length of hospital stay. There was, however, no significant difference in the rates of postoperative ileus, vomiting and abdominal distension, time to passage of flatus, time to the first passage of stool, postoperative nasogastric tube placement, febrile morbidity, wound complications and pneumonia. The policy to adopt early oral intake should be individualised but appears safe.4

WO UND C A RE Risk factors for wound problems are very similar to infection risks, i.e. comorbidities such as obesity, malignancy, contamination and advancing patient age. Superficial breakdown is best managed by drainage and debridement. Antibiotics are usually not needed but enrolling with the help of a wound-care specialist nurse can be beneficial. Secondary suturing is usually unnecessary and the wound is left to granulate. A complete dehiscense is an alarming and potentially lifethreatening occurrence. Saline swabs are used to keep the bowel clean and protected, whilst the patient is placed in the supine position and made ready for surgery. Necrotic tissue will need to be debrided and the bowel carefully inspected. Primary closure is usually possible with a non-absorbable suture using a mass closure technique. On occasion, if the abdomen is under tension, or there is concern about intestinal pathology or tissue necrosis, the assistance of a general surgeon may be helpful. Late wound breakdown may occur much later, one study showed that 35% of incisional hernias occurred 3 years after the initial surgery.

6

INFO RMA TIO N/ DEBRIEFING Following a gynaecological operation, patients should be informed fully and promptly about the findings and exactly what has been done, what the expected consequences may be and the recovery time. Relatives may wish to be party to this information, provided the patient gives their consent. If a complication has occurred it is important to give a full explanation and apology if appropriate. Debriefing may take several stages depending on the complication and involvement of a relative is often desirable. It is also useful to brief staff/general practitioners looking after the patient early and accurately so that there is consistency in what is said to the patient. Staff may also need support themselves in the case of a serious event and where appropriate an internal enquiry and report should be conducted. Such an inquiry should be conducted openly and honestly against a background of a ‘no blame culture’. Having an operation is a stressful experience and patients vary in their ability to cope with this. Patients who are undergoing investigation or operations for cancer will particularly need extra support. Good psychological support has been shown to reduce analgesia requirements and anxiety. Explanation and reassurance may need to be given in several stages. Day case patients may still be drowsy from the anaesthetic when being spoken to about their operation and fail to absorb what they are told. Consent to talk to a relative and giving a written explanation of the findings is particularly important in these cases. A clear plan of management must be laid out so to the patient so that she is aware of the next steps. The availability of a telephone helpline should be available is useful for patients who need reassurance of their emotional and gynaecological findings. 77

Section A | Introduction, Anatomy, Pre-op. Diagnosis and Management, Imaging, Skill Learning, Postop. Care

Sp e c ia l C o nsid e ra tio ns DA Y SURG ERY

6

The short time of admission with day surgery cases means that leaflets, telephone numbers and facilities for re-admission must be available for patients postoperatively. They must be warned of symptoms to expect postoperatively and what should prompt them to seek advice. And how to obtain it.

THE O BESE PA TIENT Obesity considerably increases the operative and postoperative risks. In particular, there is an increased incidence of thromboembolism, infection and anaesthetic complications. Extra care with all aspects of care is needed to reduce these risks to a minimum.

Re fe re nc e s

LA PA RO SC O PIC SURG ERY The advantages of laparoscopic surgery include rapid recovery, less, blood loss, tissue damage/adhesion formation, less pain and impaired mobility and hence a quicker recovery compared to open procedures. Most of the complications related to laparoscopic surgery are related to the method of entry into the peritoneal cavity. To minimise the risk, a number of recommendations have been made for a safe entry technique (see Chapter 3). The most common complications are bowel injury (0.4–3 per 1000) and vascular injury (0.2–1 per 1000).8 Failure to recognise and deal with these immediately, often by laparotomy, will lead to greatly increased morbidity and even mortality.

1.

2.

3.

4.

5.

HYSTERO SC O PY The most frequent complications associated with hysteroscopy are uterine perforation (which may be associated with damage to bowel or blood vessels) and fluid absorption. If perforation is suspected, early recourse to diagnostic laparoscopy is necessary, leading to laparotomy and assistance from a surgical colleague if intestinal or difficult vascular damage is found. Excessive fluid absorption at hysteroscopy is more common if the procedure has been lengthy, or when large vessels have been opened at endometrial or fibroid resection. It is always important to monitor fluid input and output of the hysteroscopic fluid. Excessive fluid absorption can lead to hyponatraemia and hypo-osmolality. This may be characterised clinically by nausea, vomiting, seizures and coma. It is therefore important to closely monitor those at risk of developing such a complication.

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6.

7. 8.

National Patient Safety Agency. Recognising and responding appropriately to early signs of deterioration in hospitalised patients; 2007. National Patient Safety Agency. WHO Surgical Safety Checklist (adapted for England and Wales): Patient Safety Alert. National Patient Safety Agency. Jan. 2009. American Society of Anaesthesiologists Task Force on Acute Pain Management. Practice guidelines for acute pain management in the perioperative setting. Anaesthesiology. 2004;100:1573–81. Charoenkwan K, Phillipson G, Vutyavanich T. Early versus delayed (traditional) oral luids and food for reducing complications ater major abdominal gynaecologic surgery. Cochrane Database Syst Rev. 2007;17(4):CD004508. Niel-Weise BS, van den Broek PJ. Urinary catheter policies for short-term bladder drainage in adults. Cochrane Database Syst Rev. 2005;(3):CD004203. NICE Clinical Guideline 92. Venous thromboembolism: reducing the risk. Reducing the risk of venous thromboembolism (deep vein thrombosis and pulmonary embolism) in patients admitted to hospital); January 2010. NICE Clinical Guideline 74. Surgical site infection: Prevention and treatment of surgical site infection; October 2008. Royal College of Obstetricians and Gynaecologists. Preventing entry-related gynaecological laparoscopic injuries; 2009.

Furthe r Re a d ing Scottish Intercollegiate Guidelines Network. Postoperative management in adults. 2004. Guideline 77.

SECTION

Be nig n C o nditio ns: The C e rvix, Va g ina a nd Vulva , Ute rus, O va rie s a nd Fa llo pia n Tub e s SEC TIO N O UTLINE 7. Ce rvix, Va g ina a nd Vulva ... 81 8. Co ng e nita l Ano ma lie s o f the Ge nita l Tra c t ... 103 9. The Ute rus ... 131 10. The Ova rie s ... 195 11. End o me trio sis ... 201 12. The Fa llo p ia n Tub e ... 207

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C e rvix, Va g ina a nd Vulva

7

Carl Chow

During the last few decades, there have been enormous improvements in the equipment used in both the investigation and surgical treatment of diseases of the lower genital tract. We have also seen significant advances in high-resolution imaging including both ultrasound and magnetic resonance imaging, which have aided in the subsequent surgical management of lower genital tract disease. However, the need to undertake surgical diagnostic procedures remains. Improved camera optics and digital technology have greatly improved real-time imaging. New modalities of treatment have enabled many procedures to now be undertaken in an out-patient setting under a local anaesthetic, rather than general anaesthesia.

AMPUTATIO N (TRAC HELEC TO MY) Total removal of the cervix may be required for the development of cervical pathology following sub-total hysterectomy. Radical trachelectomy is now increasingly being undertaken in the treatment of young women with early stage cervical cancer, where there is a desire to preserve fertility (see Section D, Chapter 16).

Te c hniq ue s DILATATIO N Standard vaginal and cervical toilet is required.

O pe ra tio ns o f the C e rvix DILATATIO N Dilatation of the cervix is required to permit both diagnostic and therapeutic procedures of the uterine cavity. With the use of high-resolution optics, one is able to use smaller diameter instruments in order to visualise the uterine cavity and hence the need to dilate the cervix rarely needs to exceed 5–6 mm, thereby minimising potential trauma to the cervix itself. Therapeutic dilatation of the cervix to larger diameters may be required for vaginal termination of pregnancy, especially in the late first and early second trimester of pregnancy. However, it is essential to consider the use of hormonal agents such as prostaglandins (e.g. misoprostol) to aid softening of the cervix and therefore minimise the force required to achieve the necessary dilatation. In the non-pregnant state, dilatation of the cervix is a treatment for pyometra (and occasionally haematometra) and as a prelude to therapeutic insertions of devices such as intra-uterine contraceptive devices or radioactive sources.

EXC ISIO N BIO PSY Local lesions such as cervical polyps may need excision if sessile. Colposcopically directed punch biopsy is essential for the diagnosis of cervical intra-epithelial neoplasia (CIN). Excision biopsy, i.e. LLETZ/large loop excision is now the most common method of treatment for high-grade CIN.

Bimanual Examination of the Patient: This examination is essential prior to any form of surgical instrumentation. The objective is to determine the precise size and position of the uterus, in particular whether it is acutely anteverted/retroverted. It is also important to examine the adnexae, in order to identify the presence of any masses. Exposure of the Cervix: A Sims’ speculum is introduced into the posterior vagina to expose the cervix. The anterior lip of the cervix is grasped with either a tenaculum or vulsellum forceps and drawn down. The Introduction of the Dilator: There is some variation in the technique, according to the type of case. In nulliparous patients, a uterine sound may be introduced into the cervical canal and passed through the internal cervical os. If the uterus is anteverted, the curvature of the sound is directed anteriorly to conform with the curvature of the uterus, while if the uterus is retroverted, the curvature of the sound is directed posteriorly. Undue pressure on the sound must never be used to determine the direction of the uterine cavity and position of the internal cervical os. If the cavity of the uterus cannot be found with the sound, a small blunt-pointed probe can instead be used. With patience and care, the internal os will eventually be passed and the cavity of the uterus entered. A sound can subsequently be introduced and the length of the uterine cavity measured, after which the cervix can be gradually dilated using metal dilators. Various types of dilator are available, although the original Hegar type is still the most commonly used. Other dilators are available which increase in size along their length. The operator

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should always be certain that the internal os has been passed by the dilator, and should also be able to tell exactly when the tip of the dilator comes into contact with the fundus of the uterus. One must be careful to avoid exerting excessive force, thereby increasing the risk of either uterine or cervical perforation. Particular care should be exercised in both nulliparous and post-menopausal patients. The dilatation should be performed slowly, and the metal dilator should remain in the cervical canal for a short time after it has been introduced. If the dilator cannot then be removed easily, or if it is still grasped firmly by the cervix, it should be left in position until it may be removed with ease. The cervix can be dilated in this way to No.8 Hegar for a diagnostic curettage procedure. Dilators which increase by only 0.5 mm should be used for termination of pregnancy in order to minimise the risk of cervical trauma. During a routine procedure, little difficulty is usually experienced in finding the internal os. Small dilators can usually be passed quite easily, particularly if the patient is multiparous. In order to minimise the risk of perforation, the following technique is suggested. The surgeon holds the vulsellum in the left hand and only gentle downward traction is applied. This reduces the risk of the vulsellum teeth cutting through the cervix. The dilator is held like a pencil in the right hand and the ulnar border of this hand is firmly pressed against the patient’s left buttock (Fig. 7.1). This reduces the force which can be

Fig. 7.1: Dilatation of the cervix. A Sims’ speculum has been introduced and is held in position by an assistant. The anterior lip of the cervix is drawn down with vulsellum forceps and kept in position by the left hand of the surgeon. The dilator is held in the right hand of the surgeon.

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applied to the dilator and the patient’s left buttock acts as a buffer should obstruction to the passage of the dilator suddenly gives way followed by a jerk forward. If a given dilator will not pass without undue force, the operator should drop back one size, re-insert it and wait for a short interval before proceeding again up the scale. In pregnancy, the cervix is softer, therefore more susceptible to trauma from the vulsellum. Dilatation is often easier after delivery or spontaneous abortion. Cervical ripening is to be recommended before attempting dilatation during pregnancy. Dilatation of the cervix up to Hegar 4 can usually be achieved without anaesthesia in a multiparous patient before insertion of an intra-uterine device or endometrial biopsy. Otherwise, a para-cervical block using local anaesthetic, e.g. 2% Lidocaine may be used. Dilatation of the cervix can very occasionally result in an acute vasovagal episode and in rare cases, even cardiac arrest. It should not therefore be regarded as a minor procedure and resuscitation equipment/staff must be immediately available, especially in the out-patient setting should the need arise.

C ERVIC AL C ERC LAG E

Introduction Prematurity is the leading cause of perinatal death and disability. Preterm birth before 37+0 weeks of gestation accounted for 7.6% of all live births in England and Wales in 2005. Although preterm birth is defined as delivery before 37+0 weeks of gestation, the majority of prematurity-related adverse outcomes relate to birth before 33+0 weeks of gestation. Mortality increases from about 2% for infants born at 32 weeks of gestation to more than 90% for those born at 23 weeks of gestation. Two-thirds of preterm births are the consequence of spontaneous preterm labour and/or preterm pre-labour rupture of membranes (PPROM). The rate of spontaneous preterm birth continues to rise globally despite efforts aimed at prevention, and interventions aimed at reducing preterm birth have been largely disappointing. Cervical cerclage was first performed in 1902 in women with a history of mid-trimester abortion or spontaneous preterm birth suggestive of cervical ‘incompetence’, with the aim of preventing recurrent loss. Cervical incompetence is an imprecise clinical diagnosis frequently applied to women with such a history where it is assumed that the cervix is weak and unable to remain closed during the pregnancy. However, recent evidence suggests that rather than being a dichotomous variable, cervical ‘competence’ is likely to be a continuum influenced by factors related not solely to the intrinsic structure of the cervix but also to processes driving premature effacement and dilatation. While cerclage may provide a degree of structural support to a ‘weak’ cervix, its role in maintaining the cervical length and the endocervical mucous plug as a mechanical barrier to ascending infection may be a more important function.

Cervix, Vagina and Vulva

Dełnitions Previous terminology (prophylactic, elective, emergency, urgent, rescue) of cervical sutures (cerclage) can be ambiguous. More appropriate nomenclature based on indication for cervical suture is recommended. The terms below are increasingly used in the scientific literature. History-indicated cerclage: Insertion of a cerclage as a result of factors in a woman’s obstetric or gynaecological history that increase the risk of spontaneous second-trimester loss or preterm delivery. A history-indicated suture is performed as a prophylactic measure in asymptomatic women and normally inserted electively at 12–14 weeks of gestation. Ultrasound-indicated cerclage: Insertion of a cerclage as a therapeutic measure in cases of cervical length shortening seen on transvaginal ultrasound. Ultrasound-indicated cerclage is performed on asymptomatic women who do not have exposed fetal membranes in the vagina. Sonographic assessment of the cervix is usually performed between 14 and 24 weeks of gestation. Rescue cerclage: Insertion of cerclage as a salvage measure in the case of premature cervical dilatation with exposed fetal membranes in the vagina. This may be discovered by ultrasound examination of the cervix or as a result of a speculum/physical examination performed for symptoms such as vaginal discharge, bleeding or ‘sensation of pressure’. Transvaginal cerclage (McDonald): A transvaginal pursestring suture placed at the cervicovaginal junction without bladder mobilisation.1 High-transvaginal cerclage (Shirodkar): A transvaginal pursestring suture placed following bladder mobilisation to allow insertion above the level of the cardinal ligaments.2 Transabdominal cerclage: A suture performed via a laparotomy or laparoscopy, placing the suture at the cervicoisthmic junction.3 Occlusion cerclage: The occlusion of the external cervical os by placement of a continuous non-absorbable suture. This intervention is based on the theory behind that it is the retention of the mucous plug which is important in the prevention of preterm labour.

Pre-operative Management There is absence of data to support genital tract screening before cerclage insertion. However, in the presence of a positive culture from a genital swab, a complete course of sensitive antimicrobial eradication therapy before cerclage insertion would be recommended. There are no studies evaluating the benefit of screening for genital tract infection before insertion of a cerclage. Before any type of cerclage insertion, the patient should be informed of the following: There is a small risk of intra-operative bladder damage, cervical trauma, membrane rupture and bleeding during

insertion of cervical cerclage. Shirodkar cerclage usually requires anaesthesia for removal and therefore carries the risk of an additional anaesthetic. Cervical cerclage may be associated with a risk of cervical laceration/trauma if there is spontaneous labour with the suture in place. Cerclage insertion is associated with a doubling in risk of maternal pyrexia but no apparent increase in chorioamnionitis. Cerclage insertion is not associated with an increased risk of PPROM, induction of labour or Caesarean section. The insertion of a cervical suture is not associated with an increased risk of preterm delivery or second trimester loss.

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It is good practice to offer a first-trimester ultrasound scan and screening for aneuploidy before the insertion of a historyindicated suture, to ensure both viability and the absence of lethal/major fetal abnormality. Before an ultrasound-indicated or rescue cerclage, it is good practice to ensure that an anomaly scan has been performed recently.4

Technique Prophylactic cervical cerclage may be carried out after first trimester screening (11–14 weeks). Regional anaesthesia is generally preferable. Trauma to the cervix is minimised by using sponge-holding forceps. A small transverse incision is made at the junction of the smooth vaginal portion of the cervix with the rugose vagina of the anterior vaginal wall. A small incision is made in the posterior fornix diametrically opposite to allow the insertion of an aneurysm needle or some other suitable curved suture passer. A band of non-absorbable material is passed around the cervix and tied anteriorly. It is necessary to make a second incision posteriorly where the ligature may be extracted and reinserted to complete the tour. In practice it is rather easier to use a needle on a needle holder and pass the stitch round in a series of bites. At the onset of labour, the ligature is divided and removed. If delivery is undertaken by Caesarean section, the cervical suture should be removed. The choice of material is personal. Both wire and monofilament nylon tend to cut through the cervix. A tape of nylon is preferable. Thick braided nylon is also acceptable (Fig. 7.2). McDonald5 reported the results of the operation in 269 patients in which he achieved at least 70% success (Fig. 7.3). There is no evidence to support the use of routine perioperative tocolysis. In most of the existing randomised studies, the majority of women allocated cerclage also received perioperative tocolysis, most commonly indomethacin. Consequently, there is no control group available for comparison. However, a retrospective cohort study involving 101 women who underwent ultrasound-indicated cerclage reported that the rate of preterm birth before 35 weeks of gestation was not significantly different in women who received indomethacin for 48 hours following the procedure compared with those who did not (39% versus 34%). If ‘a rescue’ cerclage is being performed when cervical dilatation has already occurred, many obstetricians advocate the use of a tocolytic agent, e.g. Atosiban both before and after the cerclage procedure. 83

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Fig. 7.2: Cervical cerclage (Shirodkar method). The cervix is drawn downwards with a vulsellum. A small incision has been made in the anterior fornix and a similar one in the posterior fornix. An aneurysm needle has been passed from the posterior incision round the cervix so that its point presents in the anterior wound, where it is threaded with the ligature. When withdrawn through the posterior incision one half of the cervix is circumnavigated by the ligature and a similar manoeuvre on the other side will completely enclose the cervix in the ligature which is then tied with the requisite degree of tension, thus effectively closing the incompetent canal.

Fig. 7.3: Cervical cerclage (McDonald’s method). This gives equally satisfactory results and is technically somewhat easier than inserting a Shirodkar suture. Good surgical exposure with adequate retraction is essential for both methods of cervical cerclage.

field. Many colposcopes are also fitted with a green filter, which can be useful for highlighting vascular patterns. The colposcope can equally be used to conduct a detailed examination of both the vagina and vulva. Initially, colposcopy was restricted almost exclusively to German-speaking countries. However, by the 1970s, the technique began to gain wider acceptance and in the modern

C O LPO SC O PY

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In 1925, Hans Hinselmann devised the original colposcope from which the modern day instrument has been derived (Fig. 7.4).6 He developed an instrument that allowed visual inspection of the uterine cervix to be undertaken under magnification. The modern colposcope consists of a binocular microscope with different powers of magnification ranging from approximately 6 to 40 times. The lowest magnification (6×) provides a view of the whole cervix and part of the vagina. Higher magnifications allow assessment of finer colposcopic details, such as atypical vessel patterns, e.g. mosaicism and punctuation, after the application of acetic acid (3–5%) to the cervix. The greater the magnification, the smaller the diameter of the observed field visualised. A suitable colposcope should provide excellent image definition, which should not be lost upon increasing magnification, particularly when observing fine details. The focal length (the distance between the front of the lens of the colposcope and the surface of the cervix) should be 250–300 mm. This distance is necessary to allow for manipulation of instruments without interfering with the visual

Fig. 7.4: A modern day colposcope, mounted on a mobile stand, with a movable arm and cold light source. It offers binocular magniłcation from 6× to 40×.

Cervix, Vagina and Vulva era, together with cytology and now HPV testing, colposcopy is fundamental to the detection of both precancerous and cancerous lesions of the cervix. It is used in the diagnosis of cervical lesions determining the location, size and extent of such lesions; at the same time it serves for directing the site of biopsies and for selecting the most appropriate treatment.

Instrumentation 1. The colposcope consists of a series of magnifying lenses together with a potent light source (Fig. 7.4). The intensity of light is adjustable and is provided by a cold light source, which offers bright illumination and clarity of image, indispensable for capturing both still and moving images (video capture). The instrument is mounted on a mobile arm. This enables smooth, efficient and fine movements to be undertaken, thus facilitating examination of the area under investigation. The arm on which the optical part of the apparatus is mounted has been designed to enable free and easy movement in both vertical and horizontal directions, as well as inclination of the head of the colposcope to follow the axis of the vagina. 2. Other imaging equipments: Digital image capture can be achieved with the aid of a three chip CCD camera (Fig. 7.5a), attached to the colposcope (Fig. 7.5b). This is extremely useful, not only for teaching purposes, but because it also allows objective comparisons between examinations undertaken at different times and by different colposcopists. Digital image capture systems are now widely available and are proving to be an invaluable aid in the training of new colposcopists. At the same time, such a system can help to minimise the number of observers present during an examination, thereby reducing the level of anxiety/discomfort to a patient in what is, after all, an intimate examination. Digital image capture and storage can also be used to help audit colposcopic accuracy and practice. Video colposcopy and capture can also be undertaken with appropriate hardware and software. Such systems have been used in remote settings and the resultant images and video files have been transmitted over long distances for expert colposcopic review. 3. Clinic equipment: An appropriate couch must be available in the clinic with lithotomy leg supports and the ability to rise/fall/tilt in various planes, to enable an optimal view of the cervix to be obtained (Fig. 7.6a). When performing a diagnostic colposcopy, the following items should also be available: Different sizes of Cusco speculae; materials for taking liquid-based cervical smears, endocervical forceps (e.g. Desjardins, Kogan), punch biopsy forceps (e.g. Eppendorfer or Tischler forceps), small cotton wool tips or buds, cotton wool balls, 3% or 5% acetic acid solution, Lugol’s iodine solution, single tooth tenaculum, silver nitrate sticks and Monsel’s solution (see Fig. 7.6b).

Technique of Colposcopic Examination A colposcopy examination should ideally be undertaken in the absence of menstrual or indeed any vaginal bleeding and before any other gynaecological examination, which might potentially cause trauma to the cervix. The steps are detailed as follows: 1. The patient is placed in the lithotomy position; an appropriate sized Cusco speculum is carefully inserted into the vagina, taking care to avoid any trauma to the cervix. In situations where the vagina is lax or the patient is pregnant, the introduction of a latex glove over the speculum and the cutting of the end of the ‘finger’ will assist with lateral retraction of the vaginal walls as seen in Fig. 7.7. 2. After gentle swabbing, to remove any mucus or blood, the cervix is inspected at ‘low power’ magnification in order to assess its shape and size, evidence of laceration and the presence of any overt abnormality. A cervical smear or endocervical swab (infection screen) may be taken at this stage. 3. Following preliminary inspection of the cervix, some colposcopists choose to apply normal saline and then attempt to visualise the underlying blood vessel patterns by applying the green filter to the colposcopic lens. 4. Application of 3–5% acetic acid. The cervix is washed with an aqueous solution of 3–5% acetic acid. Depending upon

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(a)

(b) Fig. 7.5: (a) A small, light-weight three chip CCD camera. (b) A CCD camera attached to colposcope.

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(a)

(b)

Fig. 7.6: (a) An examination couch with lithotomy supports. (b) A trolley containing equipment required to undertake a colposcopy examination.

Fig. 7.7: A ‘gloved’ Cusco speculum—used to deal with laxity of the vaginal walls which will impair complete visualisation of the cervix.

the strength used, areas of acetowhite change may appear on the ectocervix within 15–20 seconds, allowing clear observation of morphological details, the normal process of squamous metaplasia as well as features perhaps indicative of HPV infection or indeed CIN. The acetic acid precipitates nucleoproteins and abnormal epithelium may appear white. However, these changes are reversible and will disappear with time. If the colposcopic examination takes a particularly long time, additional acetic acid should be re-applied. Normal mature squamous epithelium will remain unaltered as opposed to metaplastic or abnormal epithelium, which will take up the dye and appear white. The intensity of acetowhite change, its duration, as well as speed of uptake and disappearance are directly related to the severity of CIN. An attempt should be made to visualise 86

the endocervical canal and define the upper limit of the transformation zone, which may be assisted through the use of endocervical forceps, e.g. Desjardins and Kogan forceps (see Fig. 7.8a,b). 5. Schiller’s test is where a solution of iodine (Lugol’s iodine solution) is applied to the cervix following the application of 3–5% acetic acid. This procedure allows a clear distinction between normal mature squamous epithelium, which stains mahogany brown and other types of epithelium, including immature squamous epithelium, abnormal epithelium (CIN) and columnar epithelium, all of which tend to take up the iodine stain relatively poorly. Although many colposcopists consider that the application of Lugol’s iodine adds little value to the overall colposcopic impression, positive iodine staining can help to differentiate normal from abnormal tissue and also acts as a guide to ectocervical excision margins during treatment. 6. After examining the cervix, the vagina and vulva should also be carefully inspected. The speculum is slowly removed under colposcopic vision so that epithelium of both the anterior and posterior, as well as the lateral walls of the vagina, can be visualised. 7. Following completion of the examination, the colposcopic findings should be carefully documented. The final assessment should include a recording of the colposcopic findings, either by hand or through the saving of digital images and annotation. The site of any colposcopically directed biopsies should also be recorded. In addition, the type of transformation zone should be noted, i.e. whether the upper limit of the transformation zone can be fully visualised.

The Transformation Zone This is defined as that area enclosed between the original squamo-columnar junction at its outermost margin and the new squamo-columnar junction at its innermost aspect

Cervix, Vagina and Vulva

7

(a)

(b)

Fig. 7.8a,b: Endocervical forceps – Desjardins and Kogan forceps, which can be used to remove mucus, visualise the endocervical canal and attempt to dełne the upper limit of the transformation zone.

(Fig. 7.9a). During late fetal life and in adolescence, but mainly during the first pregnancy, the more caudal area of the original columnar epithelium is partially or completely replaced with squamous epithelium, by the physiological process of squamous metaplasia (Fig. 7.9b). This dynamic change introduces instability to the junctional interface between the two original epithelial types and it is this process that is subject to disruption by HPV infection and hence the potential development of cervical neoplasia. The colposcopic features of the transformation zone are dependent upon both age and a woman’s hormonal status. In the pre-pubertal cervix, eversion of the cervix is minimal. In contrast, during pregnancy there is much greater eversion, which may result in the formation of a cervical ectropion (Fig. 7.10a,b). The size of the transformation zone can vary signifi-

(a)

cantly and it is always important to undertake a thorough examination of the whole cervix and upper vagina. Only when one has been able to visualise the whole transformation zone can the colposcopy examination be deemed satisfactory. In a small number of women (4%) the transformation zone extends onto the walls of the vaginal vault. Figure 7.11 illustrates this situation. This Mullerian duct epithelium is subject to the same acidic environment as the rest of the ectocervix and will undergo metaplasia, hence the fine acetowhite changes visible after the application of 3–5% acetic acid. This area has been termed the congenital transformation zone and since it may undergo metaplasia, it is also vulnerable to neoplastic change. This will have implications in terms of treatment, should a high-grade lesion be found within the transformation zone on the ectocervix.

(b)

Fig. 7.9a,b: An illustration of the different types of cervical epithelium (original squamous, original columnar), the presence of immature squamous metaplasia and the position of the new squamo-columnar junction.

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During the metaplastic process, the epithelium is vulnerable to a genetic change that may result in the tissue acquiring a neoplastic potential. This type of epithelium has distinctive morphological characteristics and possesses the same topographical arrangement within the transformation zone as the physiological epithelium. The transformation zone in this situation is termed the atypical transformation zone and within its area will reside the precursors of squamous cervical cancer.

MIC RO C O LPO HYSTERO SC O PY Microcolpohysteroscopy (MCH) was first described by Hamou in 1980.7 It allows the gynaecologist to perform either a panoramic or in vivo microscopic visual inspection of the

cervix and to combine colposcopic, cytological and histological findings in the course of the same examination. The Hamou microcolpohysteroscope is an endoscope, 4 mm in diameter (5.2 mm sheath), 25 cm length, with 90° field angle and 30° forward oblique scope, allowing the instrument to be used in a panoramic or contact mode at different magnifications. The system of lenses includes two ocular, one being directed in line (with magnifications ×1 in panoramic vision and ×60 for contact work) and one lateral (with magnifications of ×20 for panoramic vision and ×150 for contact work). Light is provided by a standard 150 W cold light source. In vivo examination of the surface cells of the ectocervix and cervical canal is facilitated by additional stains, i.e. Lugol’s iodine 2% for visualisation of mature squamous cells containing glycogen and Waterman’s blue ink for the detection of dysplastic and metaplastic cells. Examination of the cervix involves careful cleansing of the cervix with saline-soaked cotton swabs (acetic acid causes denaturation of proteins altering the appearance of cells through the optic instrument) followed by staining of the cervix with Lugol’s iodine and Waterman’s blue. There is no need for focusing because the objective is always in contact with the mucosa. Examination should be performed in a clockwise direction, which facilitates the endoscopist’s orientation when the tissue is biopsied as well as the identification of the site of lesions and the squamo-columnar junction. Initially, the lowest magnification should be used for a general inspection followed by the highest magnification for detailed examination. Microcolpohysteroscopy allows detection of normal metaplastic changes, HPV and the spectrum of cervical intraepithelial neoplasia. It is certainly capable of showing some lesions within

(a)

3

2 1

(b) Fig. 7.10a,b: Cervical ectropion—the presence of columnar, endocervical epithelium on the ectocervix. This phenomenon is particularly common during puberty and in pregnancy. It may also be seen in young women taking the combined oral contraceptive pill. Patients often present with symptoms of excess vaginal discharge or post-coital bleeding.

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Fig. 7.11: The endocervix is marked at (1) and the original squamo-columnar junction is shown at (2). The squamo-columnar junction (3) encloses a shaded area that denotes where columnar epithelium has extended onto the vaginal vault. (Modiłcation of the diagram originally produced by the late Dr Ellis Pixley of Perth, Western Australia.)

Cervix, Vagina and Vulva the endocervical canal which are undetectable by colposcopy. Biopsies can then be taken accordingly.

C e rvic a l Bio psy INTRO DUC TIO N The major aim of all organised cervical screening programmes around the world is to reduce the incidence of cervical cancer. In countries, where organised screening takes place, patients with abnormal cytology are referred for colposcopy examination. Where an abnormality is identified, a colposcopically directed biopsy may be taken and the histology result used to guide subsequent management, which may involve excision treatment. However, in many countries around the world, colposcopy is still often used as a primary screening tool. Naked-eye visual inspection (VI) of the uterine cervix, after application of 5% acetic acid (VIA) and/or of Lugol’s iodine (VILI), provides simple tests for the early detection of cervical precancerous lesions and early invasive cancer in the developing world/low-resource settings. VILI is similar to the Schiller’s iodine test, which was used for early detection of cervical neoplasia in the third and fourth decades of the twentieth century, but discontinued after the advent of cervical cytology testing. The potential difficulties in implementing cervical cytology-based screening in such environments have prompted the investigation of the accuracy of alternative low-technology tests such as VIA and VILI in the early detection of cervical neoplasia. The advantages of such techniques are that the results of inspection are immediately available and do not require any laboratory support. The categorisation of the results of VIA or VILI depends upon the colour changes observed on the cervix. A clear understanding of the anatomy, physiology and pathology of the cervix is absolutely essential to understand the basis and to interpret the outcome of screening using VIA and VILI, hence the need for rigorous training and educational support. Other conditions may cause confusion to the untrained eye. Leukoplakia (hyperkeratosis) is a well demarcated white area on the cervix (before the application of acetic acid), due to keratosis, visible to the naked eye. Usually leukoplakia is idiopathic, but it may also be caused by chronic foreign body irritation, HPV infection, or squamous neoplasia. Condylomata or genital warts are often multiple, exophytic lesions that can occur on the cervix (Fig. 7.12a,b) and also within the vagina and on the vulva, caused by infection with HPV, commonly with subtypes 6 and 11. They may also present as a diffuse, greyish-white, lesion involving areas of the cervix and vagina. Condylomata may be obvious to the naked eye (before the application of acetic acid).

diathermy cauterisation may be required. Directed biopsies are performed under colposcopic guidance, which should therefore render a high degree of diagnostic accuracy. On occasion, multiple biopsies may be required, in order not to miss a highgrade lesion. There are many different types of biopsy instruments, all of them formed by a fixed arm and a mobile cutting part. Examples below include Eppendorfer and Tischler biopsy forceps (Fig. 7.14a–c). In order to take biopsies of lesions on the margin of the external os, the fixed part of the forceps should be introduced into the endocervical canal, with the mobile part lying outside (Fig. 7.13b). Where more than one sample is required on both anterior and posterior lips of the cervix, the area within the posterior lip should be biopsied first, in order to prevent problems with visualisation of lesions related to bleeding from the superior-most biopsy site. A single or multiple colposcopically directed punch biopsies may be required to confirm the diagnosis of a clinically visible

7

(a)

PUNC H BIO PSY This method is used to obtain small quantities of cervical tissue with little, if any, anaesthetic requirement (Fig. 7.13a,b). Following biopsy, there may be a small amount of bleeding which can usually be stopped using silver nitrate sticks (Fig. 7.13c) or if persistent, a small application of Monsel’s solution. Rarely,

(b)

Fig. 7.12a,b: A cervical wart. Despite the obvious appearance of the wart, it is important to exclude the possibility of signiłcant pre-cancerous or indeed invasive changes in the epithelium below.

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(a)

(b)

(c) Fig. 7.13: (a) Inłltration with 2% lidocaine. (b) Fixed part of Eppendorfer forceps in endocervical canal. (c): Cautery using silver nitrate sticks.

90

(a)

(b)

(c) Fig. 7.14: (a) Eppendorfer forceps. (b) Fixed arm and a mobile cutting part. (c) Tischler forceps.

Cervix, Vagina and Vulva lesion. Complete excision of the transformation zone is not always required in every instance, e.g. the management of lowgrade disease.

C O NE BIO PSY For most patients where the squamo-columnar junction is fully visible, they may be treated by a standard LLETZ procedure, which will be discussed later. However, there are a group of patients with significant intra-epithelial abnormalities, in whom even with careful colposcopic evaluation, the squamo-columnar junction is not fully visible. They, in particular will need to undergo some form of cone biopsy of the cervix. The objective of undertaking such a biopsy is to excise the entire transformation zone and any abnormal glandular epithelium, so that comprehensive histological analysis may be undertaken and excision margin status determined. Common indications for cone biopsy are listed below: 1. Suspicion of micro-invasive carcinoma or occult invasive carcinoma. 2. Suspicion of high-grade glandular disease. 3. Incompletely visible transformation zone in women with high-grade CIN (CIN 2/3). 4. Significant disparity between cytology and colposcopy. 5. Positive endocervical excision margins, particularly in women over 50 years of age, who have already undergone treatment of high-grade CIN. The potential morbidity of cone biopsy is such that the routine use of this procedure is to be avoided. Appropriate colposcopic assessment, together with the additional use of endocervical forceps may identify the upper limit of the transformation zone and hence allow the depth of excision to be tailored accordingly. Complete excision with clear margins (endocervical and ectocervical) is regarded as adequate treatment for high-grade CIN and also in cases of very early microinvasion of the cervix (Stage 1A1 disease), especially where it is desirable to retain reproductive function. Clear guidance has been issued by the NHS Cervical Screening Programme (NHSCSP) with regard to the follow-up of women who have been treated for CIN (all grades).

made with a sharp-pointed thin-bladed knife, such as a long tenotome, around and well outside the area of abnormality (Fig. 7.15). A small tenaculum is then applied to the base of the cone and gentle downward traction applied, whilst the vulsellum on the cervix exerts traction in an upward direction. The incision is then deepened with circular sweeps until the region of the internal os is reached which forms the apex of the cone. It is important to make a wide excision of the whole length of the endocervix, in order to include any potential areas of abnormality within the endocervical canal. Bleeding from the base can be quite considerable after removal of the specimen, but more usually there is a general oozing from the base of the cervix. Haemostasis is often achieved using local diathermy coagulation (rollerball), although occasionally the cavity may have to be closed by a double Sturmdorf suture (Fig. 7.16). A deep suture at both three and nine o’clock will help secure haemorrhage from the cervical branch of the uterine artery. In the upper left diagram, the blood vessels which lie laterally are underpinned and ligated. A long suture is introduced as shown in the vaginal wall posteriorly. In the upper diagram on the right side, the needle has then been passed through the whole thickness of the cervix to emerge through the vaginal wall. The needle is then threaded through the other end of the suture and passed as shown. When the suture is tied, the posterior part of the raw area is covered. A similar suture is introduced anteriorly; finally lateral sutures are placed to cover the raw area completely. Alternatively a series of ‘reefing’ sutures may be applied to approximate ectocervical and endocervical epithelium. The advantage of this method is that the new transformation zone

7

Technique Using a knife is the traditional and in some ways the best method of obtaining a large cone biopsy of the cervix. This modality of treatment ensures that the tissue biopsy margins are free from diathermy artefact and provide the best possible specimen for histological examination. 3–5% acetic acid and Lugol’s iodine are applied to the cervix in order to identify the transformation zone and allow the excision margin to be determined. 4–5 mL of 2% lidocaine and 1 in 80,000 adrenaline are then injected intracervically to aid haemostasis (adrenaline causes vasoconstriction). The anterior lip of the cervix is grasped with a single-toothed vulsellum, applied well above the area to be excised. A circular incision is

Fig. 7.15: Cervical cone biopsy. Hysterectomy specimen incised to indicate the depth of the excision biopsy.

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7

Fig. 7.16: Extensive cone biopsy of the cervix—method used to achieve haemostasis.

formed after healing has been completed should be accessible to colposcopic examination.

Alte rna tive Me tho ds LASER C O NISATIO N Laser therapy (Fig. 7.17) may also be used for vaporisation of both low and high-grade CIN, subject to certain defined conditions being fulfilled and also for conisation.

LARG E LO O P EXC ISIO N O F THE TRANSFO RMATIO N ZO NE In 1981, at the fourth World Congress of Colposcopy and Cervical Pathology, Cartier reported his experience using a small loop to take directed biopsies and to remove the transformation zone in strips.8 This technique provided a comprehensive specimen for histology but was associated with minimal morbidity. It became known as the large loop excision of the transformation zone (LLETZ) procedure and building on Cartier’s work, further work led to the utilisation of larger loops in order to excise the entire transformation zone in a single specimen. LLETZ uses modern low-voltage diathermy electrosurgical units and insulated loops. It was also ideal as the procedure could be performed under local anaesthesia. It was introduced into clinical practice in Bristol in the early 1980s and rapidly gained widespread acceptance. The technique is known as LLETZ in the UK but its name was changed to LEEP in the USA. The major advantage of the procedure is that it achieves excision of the transformation zone using a technique that preserves histological integrity. The resulting biopsy can therefore be comprehensively examined, micro-invasive disease ruled out, excision margins 92

Fig. 7.17: Carbon dioxide laser machine.

assessed and over-treatment recognised. Also, the treatment can be applied to every circumstance where the transformation zone has to be treated, i.e. endocervical/ectocervical, large or small, containing squamous or glandular abnormalities. Lastly, the technique is outpatient-based and carries lower morbidity than the traditional cold knife cone biopsy. It is by now far and away the most common treatment procedure performed in the colposcopy clinic. It is inexpensive compared to other treatment methods and gives excellent results (95% success rates). Again, it is important to use the technique correctly in order to obtain clear excision margins and minimise diathermy artefact. One should aim to provide a single specimen rather than multiple small loop specimens in order to allow accurate interpretation of the histological changes

Cervix, Vagina and Vulva within the specimen. The target tissue is excised with a scooping motion rather than by twist and rotation. Incomplete excision of the transformation zone is known to be associated with a higher incidence of residual disease. The fact that incomplete excision does not always (or even usually) result in residual disease is likely to be due to the combined effect of diathermy damage and the inflammatory response associated with the healing wound. Why should incomplete excision occur at all? It is likely to be due to a combination of the following factors: (a) excision biopsies being too shallow for the particular transformation zone, (b) an inability to reliably recognise the upper limit of the transformation zone, (c) an inability to recognise margin status due to diathermy damage of the specimen biopsy or perhaps (d) the use of inappropriate electrodes for different procedures. The issue is further complicated by the various meanings of the nomenclature used in the literature. The term cone biopsy can mean different things in different studies and indeed countries. Most colposcopists tend to reserve the term where the

(a)

(c)

transformation zone extends some millimeters out of view up the endocervical canal. It is in this scenario that incomplete excision is most likely to occur. To try and achieve clarity and to allow comparison of results of treatment between various studies/centres, an international classification system (IFCPC) has been adopted by colposcopists reporting treatment series in the literature. This classification system is designed to be both simple to use and acceptable to practicing colposcopists, as well as being able to accommodate every treatment circumstance arising in routine clinical practice. The system has three indices by which the transformation zone may be classified. These are: (i) the size of the ectocervical component of the transformation zone, (ii) the position of the upper limit of the transformation zone, (iii) the visibility of the upper limit of the transformation zone. The three types of transformation can be characterised as being completely ectocervical, fully visible with an endocervical component, or not fully visible (see Fig. 7.19a–c).

7

(b)

(d)

Fig. 7.18: LLETZ procedure. (a) Local inłltration with 2% lidocaine and 1 in 80,000 adrenaline, (b) single diathermy loop excision, (c) removal of loop specimen, (d) rollerball diathermy to base to achieve haemostasis.

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Section B | Benign Conditions: The Cervix, Vagina and Vulva, Uterus, Ovaries and Fallopian Tubes

ENDO C ERVIC AL C URETTAG E

7

Lesions in the endocervix can be biopsied by undertaking endocervical curettage using a sharp spoon-shaped or similar grooved instrument. The volume of the material obtained is often small and mixed with blood and mucus. Endocervical curettage has been used in the investigation and follow-up of patients with cervical intra-epithelial glandular disease. Its use is not widespread in the UK but it is used much more extensively in North America.

C RYO THERAPY (FIG . 7.20) The first report of cryosurgical therapy for cervical neoplasia was published in 1967 by Crisp et al.,9 followed by several others during the 1970s. In many countries, it rapidly became the most popular treatment for CIN. This technique is a destructive/ablative technique and freezes the cervical epithelium using a cryosurgical probe. The destruction of tissue is based on achieving a temperature of -20°C with subsequent crystallisation of the intracellular water. Crystallisation in the nucleus disrupts the cell membrane, resulting in cell death.

Transformation Zone Classification Type I Completely ectocervical Fully visible Large or small

(a) Transformation Zone Classification

Many different cryosurgical probes are available and several studies have evaluated the interaction of the cryoprobe with the cervix, the necessary freeze time in order to destroy the tissue and the effectiveness of this once popular outpatient treatment modality. The refrigerant gas which cools the probe may be carbon dioxide or nitrous oxide. Nitrous oxide has been described as the preferred gas because it has a colder freezing point (-90°C) than carbon dioxide gas (-60°C). The gas tank must be kept at a constant pressure (750–830 mmHg) to adequately freeze the cryoprobe. However, in common with other ablative techniques, cryotherapy is only suitable when the following criteria are fulfilled: 1. 2. 3. 4.

The entire transformation zone is fully visualised. There is no evidence of glandular abnormality. There is no evidence of invasive disease. There is no major discrepancy between cytology and histology.

Only in exceptional circumstances should ablative treatment be considered for women over 50 years of age. According to national guidelines, cryotherapy should only be used to treat low-grade CIN and a double freeze–thaw– freeze technique must be used. A number of studies have documented that the rate of clearance of CIN 3 appears to be poorer with this particular destructive technique. The double freeze technique has a lower incidence of residual disease compared with a single freeze technique. Complications associated with cryotherapy are rare and post-treatment infection appears to be the most common. However, it appears that cryotherapy has increasingly fallen out of use, in favour of LLETZ, which is able to provide a tissue specimen for histological analysis.

Am puta tio n o f the C e rvix TRAC HELEC TO MY

Type II Has an endocervical component Fully visible

Now that local treatment of the cervix is well established, there is rarely the need for amputation of the cervix, except in a

May have ectocervial component which may be large or small

(b) Transformation Zone Classification Type III Has an endocervical component Is NOT fully visible May have ectocervial component which may be large or small

(c) Fig. 7.19a–c: Classiłcation of transformation zone.

94

Fig. 7.20: Cryotherapy. Cryoprobe with attachment suitable for treatment of the cervix.

Cervix, Vagina and Vulva patient who has had a previous sub-total hysterectomy and abnormal cytology. Partial amputation differs only in a degree from an extensive cone biopsy, and the technique is precisely similar. Complete amputation of the cervix is often an extremely difficult operation to perform if the cervix cannot be pulled down as far as the introitus. A Sims’ speculum should be introduced and the lateral vaginal walls retracted by an assistant using vaginal retractors. The anterior lip of the cervix is pulled down with vulsellum forceps and the cervix dilated with Hegar dilators. Technique: A circular incision is made around the cervix cutting through the squamous epithelium together with the subjacent cervical fascia. Difficulty may be experienced in deciding upon the level at which the circular incision should be made. It is necessary to remove all unhealthy tissue, yet sufficient tissue must be left behind to cover the raw surfaces. Anteriorly the incision must lie well below the level of the bladder sulcus, otherwise it will be necessary to mobilise the bladder by dividing the vesicocervical ligament. The cervix is then pulled to one side and posteriorly, and the endopelvic fascial tissues (which run down laterally along the cervix) exposed. A curved clamp is fixed firmly to this mass of tissue and the tissue divided with a scalpel distal to the clamp. A similar procedure is carried out on the opposite side. Operators are advised to transfix and ligate these pedicles at this stage of the operation. The fibromuscular tissue of the cervix is then cut through and the cervix amputated. It will be found most convenient to excise a cone-shaped piece of cervix, the apex of the cone lying high up in the cervical canal. Bleeding areas in the tissue of the cervix can be controlled only by the introduction of mattress sutures into the substance of the cervix. Great care must be taken to obtain complete haemostasis. Subsequently, the raw surfaces of the cervix are covered by the Bonney–Sturmdorf technique.

carcinoma can very occasionally be seen in association with a cervical polyp, hence the importance of fully investigating such a patient by ultrasound and diagnostic curettage.

C ERVIC AL STENO SIS This can result in the development of a haematometra or pyometra which can be detected by ultrasound. Dilatation and drainage of fluid on its own is insufficient; if drainage of altered blood becomes obstructed once the contents have been exposed to the air there is a potential risk of infection. The cervix should be slowly dilated to Hegar 15 and a small polythene drainage tube can be sutured in place. In the case of pyometra, the uterine wall may be very soft and uterine perforation may easily occur using a dilator. If perforation of an infected uterus is suspected, it would be prudent to undertake a diagnostic laparoscopy to confirm the diagnosis and may subsequently require an abdominal laparotomy in order to repair the damage and achieve haemostasis.

7

(a)

O the r C e rvic a l Pa tho lo g y C ERVIC AL PO LYPS (FIG . 7.21) It is usual/common practice to avulse even a large cervical polyp as an out-patient procedure. If undertaken in the out-patient clinic, certain conditions should be satisfied: 1. The polyp should be sent for histology. 2. The base should be destroyed by cauterisation. 3. There must have been no disturbance of menstruation or post-menopausal bleeding. The presence of such symptoms may require further investigation by ultrasound and perhaps diagnostic hysteroscopy. It is not unusual to find a second polyp further up the endocervical canal. Endometrial polyps can also occur co-incidentally, hence the need to exclude uterine pathology in all cases of abnormal or unusual vaginal bleeding. In post-menopausal patients, endometrial

(b) Fig. 7.21a,b: Small cervical polyps sitting within the endocervical canal.

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Section B | Benign Conditions: The Cervix, Vagina and Vulva, Uterus, Ovaries and Fallopian Tubes

C o m plic a tio n o f C e rvic a l Pro c e dure s LAC ERATIO NS O F THE C ERVIX

7

Laceration of the cervix should always be suspected if the cervical canal bleeds briskly after the passage of a large dilator. The difficulty is to assess the degree of the laceration. If the external haemorrhage is severe and arterial in type it is most likely that a cervical branch of the uterine artery has been damaged. It may become necessary to split the cervix laterally to open up the base of the broad ligament and to expose the bleeding vessels, which must then be ligated. The procedure, though serious, should present no great difficulty to surgeons familiar with the operation of vaginal hysterectomy. The most serious cases are those in which the uterine artery has been lacerated and when the bleeding is internal. An enormous haematoma may form in the broad ligament and spread upwards to the loin and perinephric region. Fortunately, this complication is extremely rare. The haematoma may be managed expectantly, alternatively one might consider selective embolisation and should consult with an interventional radiologist. Instances have, however, been recorded where the bleeding was progressive and uncontrolled and in such, laparotomy is indicated as soon as the true state is realised.

Be nig n Va g ina l C o nditio ns Re q uiring Surg e ry

for a vaginal wall cyst and to excise it without closing the urethral stoma or identifying the ectopic ureter. A fistula will thereby result. Surgical removal is a simple procedure, since the cyst is encapsulated and can be shelled out without much difficulty (Figs. 7.22 and 7.23). Occasionally, marsupialisation may be appropriate.

Fig. 7.22: Removal of a cyst of the anterior vaginal wall. A case associated with prolapse.

ANTERIO R VAG INAL C YSTS Cysts and solid tumours may be found beneath the vaginal epithelium. These may be related to anterior, posterior and lateral walls. Evans and Hughes,10 in a study of 42 cysts, concluded that the majority were of Müllerian (paramesonephric) origin, the epithelium showing all the possibilities present in Mullerian-derived ovarian tumours. Cysts arising from the mesonephric duct (Gartner’s duct) are usually anterolateral in position and have a characteristic flattened epithelium. The basement membrane is well defined and unstriated muscle is often present in the surrounding tissue. Gartner’s duct passes downwards along the lateral border of the uterus, and subsequently extends anteriorly so that ultimately it lies in the anterior vaginal wall. Very rarely small cysts develop from relics of Gartner’s duct deep to the vaginal wall in the situation of the lateral fornix. Most of the cysts are small and are recognised for the first time on routine vaginal examination performed for some other reason unconnected with the cyst. Small cysts require no treatment, but sometimes they become distended with fluid, particularly when they lie in the anterior vaginal wall, or protrude at the vaginal orifice. A cyst must be distinguished from a cystocoele, urethrocoele, ectopic ureterocoele and diverticulum of the urethra. It is a cardinal error to mistake an ectopic ureterocoele or diverticulum of the urethra 96

Fig. 7.23: Removal of a cyst of the anterior vaginal wall. The vaginal wall has been reŃected and the cyst exposed.

Cervix, Vagina and Vulva

C YSTS O F THE PO STERIO R VAG INAL WALL Cysts of this type are usually implantation cysts and result from perineal laceration during childbirth. Small pieces of squamous epithelium are buried in the deeper tissues and as a result of their proliferation cause the formation of a cyst. The cysts are lined by squamous epithelium, and usually the contents consist of sebaceous material. The cysts are commonly located in the situation of perineal scars. Usually they do not attain a great size, but most patients are anxious for the removal of any tumour, whether cystic or not, in the region of the vulva. The cyst can be removed without difficulty and no special technique is required. Very rarely dermoid cysts are found in the rectovaginal septum. They are lined by squamous epithelium which contains sebaceous glands, so that the cyst is filled with greasy material. The cysts are recognised without difficulty because the tumour is circumscribed and tense and has a different feel from either a rectocoele or an enterocoele. Removal of a dermoid cyst of the rectovaginal septum offers no technical difficulty. The posterior vaginal wall should be incised by a longitudinal incision and the tumour shelled out. Bleeding points are ligated, after which the wound in the vagina is closed by a series of interrupted sutures. A dermoid arising behind the posterior vaginal wall may, however, be a benign cystic teratoma of sacrococcygeal origin. A very careful rectal examination should be performed, and the surgeon should beware lest an operation which begins as a simple enucleation should escalate beyond all recognition.

ENDO METRIO SIS O F THE VAG INA Typical ‘blue domed’ cysts may be seen, usually in the posterior fornix (see Chapter 11).

VAG INAL ADENO SIS Much interest has been focused on this unusual condition since Herbst and Scully11 demonstrated an association with maternal ingestion of non-steroidal synthetic oestrogens in the relevant pregnancy. In this condition, there is a patchy distribution of glandular epithelium in the vagina mostly beneath intact squamous epithelium but with innumerable gland mouths present. On the cervix there is a resemblance to a classical erosion but there is often an associated epithelial ‘hood’. To the naked eye, the vaginal wall may show a red ‘cobblestone’ in appearance, but often the overlying squamous epithelium is intact, hence the failure of cytology to give much help. Colposcopy is important to delineate the extent of the disease. The importance of the condition lies in the fact that a small number of adolescent girls and young women develop adenocarcinoma in such areas.11

LEIO MYO MA O F THE VAG INA These tumours are extremely rare and take the form of round projections into the vagina. They are either spherical or oval in shape with the characteristic firm consistence of a fibroid. In

due course the tumour ulcerates and becomes infected, and may be mistaken for a carcinoma of the vagina. It can be shelled out without much difficulty and surgical removal is a simple procedure, though it may be accompanied by severe bleeding.12

STENO SIS O F THE INTRO ITUS Inadequate rupture of the hymen: This important condition occurs in varying degrees. Typically a young woman is unable to allow penetration or even use a tampon because of rigidity of the hymen. Sometimes there has been partial stretching of the hymen, but tender scarring or fissures persist, leading to secondary vaginismus because of the expectation of pain and discomfort. Instructions in the use of vaginal dilators may overcome the problem, but on occasion it may be necessary to perform a hymenectomy as in cases of imperforate hymen (see Chapter 8), or an enlargement of the vaginal introitus (see below).

7

Iatrogenic introital stricture is regrettably not rare. The commonest cause is inexpert suture of childbirth injury, either perineal laceration or episiotomy. The commonest cause is a failure to recognise the concurrence of a partial annular or circumferential tear of the posterior vestibule, with a subsequent radial laceration or episiotomy incision. The resultant injury is cruciate, but if this is not recognised and is sewn up as a single vertical repair, this will effectively narrow the introitus causing significant superficial dyspareunia once coitus has been resumed following post-natal examination. A second iatrogenic cause of introital stenosis is excessive reduction of the introital size during the perineorrhaphy part of a posterior vaginal repair (see Chapter 14). Routine reduction in introital size should be avoided. It is often unnecessary and, in any case, should be tailored to the exact local condition. Other acquired causes of introital stenosis are post-menopausal vulval atrophy (at one time termed kraurosis) or the end stage of lichen sclerosus et atrophicus (LSAV). In this, the labia minora disappear and the labia majora shrink and the introitus undergoes considerable shrinkage. Functional stenosis results from muscular spasm, for which the underlying cause may be psychological or a response to severe local tenderness (vulvodynia).

Surgical Treatment of Introital Stenosis (Fenton’s Procedure and its Modiłcations) Broadly speaking there are two clinical varieties. The first is a simple arcuate skin flap, which may in fact conceal a virtually absent perineal body beneath it. The other situation is more complex where scarring extends cranially from the fourchette across the vestibule (navicular fossa) to the hymen, or the vestibular skin may be thin, inflamed and liable to fissures (vestibulitis). Technique: 1. A skin flap is fairly easily dealt with by a short median ‘episiotomy’ which is then repaired transversely (Figs. 7.24 97

Section B | Benign Conditions: The Cervix, Vagina and Vulva, Uterus, Ovaries and Fallopian Tubes

7

and 7.25). According to the findings, it may be necessary to perform a small perineal body reconstruction beneath this repair. Alternatively, in some cases of ‘idiopathic’ vaginismus, the superficial muscle (bulbospongiosus) is divided (Fenton’s operation). It is very important that the transverse introital skin suture line be closed with very fine high polymer sutures (or non-absorbable sutures which can be removed) to prevent re-occurrence of the tender scar. 2. Complex ‘post-surgical’ vestibular scarring requires excision down to healthy tissue. If this is left to granulate,

Fig. 7.26: Transposition Ńap to cover the area from which all scar tissue has been excised.

there is a risk of shrinkage and stricture re-formation. Under these circumstances, a small posteriorly based pedicled flap graft maybe utilised (Fig. 7.26).13

98

Dise a se s o f the Ure thra

Fig. 7.24: Enlargement of the vaginal introitus. The edges are drawn apart and the deeper tissues are drawn together with interrupted Vicryl sutures to produce a horizontal layer. Subsequently the skin edges are brought together with interrupted sutures.

PRO LAPSE O F THE URETHRAL MUC O US MEMBRANE

Fig. 7.25: Enlargement of vaginal introitus. Completion of the operation.

A minor degree of prolapse of the urethral mucous membrane is not uncommonly seen in adult women, though it is symptomless and necessitates no treatment. Severe degrees of prolapse are restricted to children and the aged. The condition is circumferential and in many ways comparable to prolapse of the mucous membrane of the rectum. In children there is usually a history of bronchitis or of worms, while a chronic cough may be one of the complaints met with the elderly patients. In addition to the factor of raised intra-abdominal pressure brought about by coughing, it must be assumed that the urethral tissues are lax so that the mucous membrane can separate from the muscle layer. The prolapsed mucous membrane becomes oedematous and congested and may cause severe local discomfort with frequency and tenesmus. If the prolapse becomes infarcted, a blood-stained discharge results. If the condition is not treated surgically, the prolapse will eventually slough. Treatment: The simplest surgical procedure is to excise the prolapsed mucous membrane and to suture the healthy margin of the urethra to the skin by a series of interrupted high-polymer sutures. Great care must be taken in placing the sutures accurately to prevent stenosis developing at the meatus. There

Cervix, Vagina and Vulva is some risk of recurrence after this operation though the immediate results are satisfactory. Better results can be obtained if the prolapsed mucous membrane is excised with a diathermy knife. It seems that scar tissue which forms around the meatus after diathermy excision tends to prevent a recurrence, particularly if radial incisions are made in the skin of the adjacent vestibule.

C YST O F SKENE’S TUBULES These small cysts are very rarely seen and take the form of a small cystic swelling to one or other side of the urethral meatus. The cyst can be excised and shelled out without much difficulty.

No n- ma lig na nt Co nditio ns o f the Vulva LO C AL SKIN C O NDITIO NS It is important to recognise when a vulval skin condition is a manifestation of a more generalised dermatological disorder. The situation is made more difficult by scratching artefacts (lichenification, hyperkeratosis). Conditions such as threadworm infestation (oxyuris vermicularis) need to be borne in mind, especially in children and scratching artefacts should not be mistaken for evidence of sexual abuse. The nomenclature for vulval skin disorders has been revised by the International Society for Diseases of the Vulva. Although lichen planus and lichen simplex can affect the vulva, the commonest lichenification is lichen sclerosus et atrophicus (LSAV).14 This is a potent source of vulval irritation (pruritus). In the past, this condition with severe irritation has been treated by local vulvectomy with some relief of symptoms. Vulvectomy is, however, a mutilating operation, which interferes with sexual function and whose benefit is often short-lived. The clinical dilemma, however, is that severe pruritus may indicate the co-existence of a hyperplastic component, now termed squamous cell hyperplasia. When there is additional cellular atypia, the condition has a pre-malignant propensity and may merge into vaginal intraepithelial neoplasia (VIN), (see Chapter 15 or undergo direct change to squamous cell cancer; more than half of all vulval cancers arise in this way. Surgery for vulval lichen sclerosus is only indicated for histologically proven associated dysplasia or failure of adequate medical treatment.15 1. Paget’s disease of the vulva: Extra-mammary Paget’s disease has a localised eczematous appearance. It is often, but not always, associated with an underlying adenocarcinoma of apocrine origin or of rectum, colon, ovary, cervix or breast.16 2. Labial cysts, fibromas, multiple sebaceous cysts: These may be removed for cosmetic reasons because of diagnostic doubt, or because they have shown a tendency to become infected.

3. Hidradenoma: These small tumours of sweat glands, if ulcerated, may be mistaken for malignancy. Local excision will suffice. 4. Viral warts (condyloma acuminatum): These can vary from a few delicate fronds scattered over the vulva and adjacent areas, to a massive tumour-like condition, giant condyloma of the vulva.17 Local treatment of warts consists of topical applications, laser therapy, cryotherapy and cautery. Rather less painful is multiple scissor excision.18 The association of wart virus infections with immunosuppressed states, including human immunodeficiency virus infection, needs to be remembered. Warts tend to regress after pregnancy, so that aggressive therapy applications should be avoided. 5. Vulvar vestibulitis: In this condition, there is exquisite local tenderness over a ‘horse-shoe’-shaped arc of the posterior vestibule with rather unremarkable physical signs. Local excision of this area has been recommended as a treatment often using the hymen to close the defect.19 Other benign conditions which may require local intervention are a lipoma, deposits of endometriosis or even large varicose veins filling from a saphena-varix.

7

LO C AL VULVEC TO MY Total (local) vulvectomy is very rarely indicated for non-malignant conditions. The principal indication would be vulval elephantiasis and the operation in such cases is not a minor one. Closure may be by an inverted ‘racquet’ or by an advancement flap from the mons (Figs. 7.27–7.29). Chronic granulomatous conditions of the vulva not fully responsive to antibiotics may retain a pre-malignant potential and therefore be considered for prophylactic local vulvectomy.20

Fig. 7.27: Vulval lymphoedema. This lesion was probably secondary to old tuberculous inguinal lymphadenitis. (By courtesy of the late Professor John Lawson).

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Section B | Benign Conditions: The Cervix, Vagina and Vulva, Uterus, Ovaries and Fallopian Tubes

Ba rtho lin’s Ab sc e ss a nd C yst INTRO DUC TIO N Although infection of Bartholin’s gland responds extremely well to chemotherapy and even acute abscesses may undergo

7

resolution without surgical intervention, there is a great tendency for recurrence of the infection. Some patients may have had several abscesses which swell up, burst and become quiescent only to repeat the process a few months later. The condition is extremely painful and may render walking unbearable. Dyspareunia is a common complaint. The usual treatment of a Bartholin’s abscess is marsupialisation. A Bartholin’s cyst results from blockage of the duct of the gland. Chronic inflammatory conditions are responsible for the occlusion of the duct, but the origin is not necessarily gonococcal. Quite a common cause of a Bartholin’s cyst is a misplaced episiotomy incision in the posterolateral position. The duct is thereby either cut or, if not transected, it becomes involved in the subsequent scar tissue. This complication should be avoided by strict attention to starting all episiotomy incisions at the midline (six o’clock) position.

MARSUPIALISATIO N O PERATIO N The treatment of Bartholin’s cysts and abscesses by marsupialisation is now the method of choice. The advantages of marsupialisation over excision are as follows:

Fig. 7.28: Local vulvectomy. The affected skin has been excised. Bleeding points have been picked up and ligatured. A catheter has been introduced into the urethra.

1. It is an extremely simple operation requiring only a few minutes for its performance, whereas excision is nearly always difficult, tedious and time consuming. 2. Haemorrhage is minimal and easily controlled, whereas the reverse certainly applies with excision. Haematoma formation after marsupialisation should not occur, whereas with excision it frequently occurs, even when drainage or packing is applied. 3. It is applicable to the treatment of the acutely inflamed gland with abscess formation as an alternative to incision and drainage. 4. It is claimed that some functional activity may be regenerated in the gland which thereby supplies lubrication to the vagina. One of the main disadvantages of bilateral excision of Bartholin’s gland and cyst is that it leaves the patient with a dry vagina, thereby causing friction dyspareunia. Technique:

100

Fig. 7.29: Local vulvectomy. The skin edges are brought together with interrupted catgut sutures. If the skin of the perineum is grossly affected, a much wider dissection is required. In such cases, the Ńap can be fashioned from the posterior vaginal wall.

1. The exact situation of the incision varies according to whether there is an abscess pointing, or simply a cyst. Ideally, it should ultimately heal with a stoma in the position where Bartholin’s duct normally opens. It is best, therefore, made on the vaginal side of the hymeneal ring. In this situation, when healed, there is less likelihood of an introital scar causing dyspareunia. The length of the incision must not be too short in order to avoid closure of the aperture during the process of healing, whereby a recurrence of the cyst or abscess is likely. 2. The incision includes the vaginal skin and cyst or abscess wall, both of which are picked up together by a pair of Allis’ forceps placed laterally and medially. 3. Two semicircles of skin and cyst wall are excised on each side of the incision and the edges trimmed to leave an aperture 1 cm in diameter (Fig. 7.30).

Cervix, Vagina and Vulva in controlling all oozing from the erectile tissues of the operation area. Subsequently, the skin incision is closed with a series of No. 0 interrupted high polymer sutures. If haemostasis is not satisfactory, a small suction drain should be inserted in the wound and left in for 24 hours. A very considerable haematoma can develop if this precaution is omitted and such a haematoma may take weeks to absorb and be most uncomfortable and time wasting for the patient. Tissue should be sent for histology if there is chronic thickening and fibrosis, as carcinoma of the gland may develop following chronic infection.

7

Re fe re nc e s Fig. 7.30: Marsupialisation of Bartholin’s cyst. Left: position of incision, top right: excision of disc of cyst and overlying skin, Bottom right: suture of cyst wall to skin.

1. 2.

4. The edges of the skin and cyst wall are again secured with Allis’ forceps and a series of fine interrupted sutures applied circumferentially at 1 cm intervals. These sutures secure apposition of the cyst wall and vaginal skin to leave a clean circular scar. After treatment: Unless the cyst is infected or a frank abscess is being treated, chemotherapy is unnecessary and all that is required is twice daily baths. If the patient is discharged early, she should be seen at the end of a week to ensure that no loculation has occurred in the cavity. It is rarely necessary to pack the cavity at the time of operation though this is good practice if haemorrhage is troublesome. Complications: 1. Failure to secure the cyst wall with Allis’ forceps may result in bleeding from the tissues intervening between the cyst wall and the vaginal skin. 2. Recurrence is usually due to a too small incision and an inadequate removal of skin and cyst wall as a result of which the stoma becomes constricted and blocked. Postoperative examination is equally important to ensure that no loculation occurs in the cavity and that this becomes obliterated from below upwards.

EXC ISIO N O F A BARTHO LIN’S G LAND Technique: Opinions differ as to the position of the skin incision. A longitudinal incision on the inner surface of the labium minus gives the best exposure, but the subsequent scar may be painful and cause dyspareunia. If the incision is placed over the convexity of the swelling immediately lateral to the labium minus these objections do not arise, but the exposure is not so satisfactory. After the gland has been removed complete haemostasis must be obtained. Deep sutures may be used to obliterate the cavity. Considerable difficulty may be experienced

3.

4. 5. 6.

7. 8. 9.

10. 11.

12. 13.

14. 15.

16.

17.

McDonald IA. Suture of the cervix for inevitable miscarriage. J Obstet Gynaecol Br Emp. 1957;64:346–50. Shirodkar VN. A new method of operative treatment for habitual abortion in the second trimester of pregnancy. Antiseptic. 1955;52:299–300. Benson RC, Durfee RB. Transabdominal cervico uterine cerclage during pregnancy for the treatment of cervical incompetency. Obstet Gynecol. 1965;25:145–55. Cervical Cerclage RCOG Green-top Guideline No. 60 RCOG (2011). McDonald IA. Cervical cerclage. Clin Obstet Gynaecol. 1980;7(3):461–79. Hinselmann H. Verbesserung der Inspektionsmöglichkeit von Vulva, Vagina und Portio. Münchner Medizinische Wochenschrift. 1925;77:1733. Hamou J. Microcolpohysteroscopie: une nouvelle technique en endoscopie. Les applications. Acta Endoscopica. 1980;10:415. Cartier R. 4th World Congress of Cervical Pathology and Colposcopy, London 1981. Crisp WE, Asadourian L, Romberger W. Application of cryosurgery to gynecologic malignancy. Obstet Gynecol. 1967;30: 668–73. Evans DMD, Hughes H. Cysts of the vaginal wall. J Obstet Gynaecol Br Commw. 1961;68:247–53. Herbst AL, Scully RE. Adenocarcinoma of the vagina in adolescence a report of seven cases including six clear cell carcinomas (so called mesonephromas). Cancer. 1970;25:745–57. Pulfuls E. Vaginal wall mass. Obstet Gynaecol Surv. 1999;54: 149–50. Hudson CN, Setchell ME. Vaginal reconstruction using laps and grats. In: Webster G, Kirby R, King L, Goldwasser B, eds. Reconstructive Urology. Oxford: Blackwells; 1993:845–56. Suter P. Lichen simplex chronicus, lichen sclerosus and lichen pianos of the vulva 0 & G (resource unit) 1999;1:317–20. Abramon Y, Elchalat V, Abramon D, Goldfarb A, Schenker JG. Surgical treatment of vulvar lichen sclerosus: a review. Obstet Gynecol Surv. 1996;51:193–9. Fishman DA, Chambers SK, Schwartz PE, Kohorn El, Chambers JT. Extramammary Paget’s disease of the vulva. Gynecol Oncol. 1995;56:266–70. Baird PJ, Elliot P, Stening M, Korda A. Giant condyloma accuminatum of the vulva and anal canal. Aust NZJ Obstet Gynaecol. 1979;19:119–22.

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homson JPS, Grace RH. he treatment of perianal and anal condylomata acuminata: a new operative technique. J Roy Soc Med. 1978;71:180–5. 19. Goetsch MF. Simpliied surgical revision of the vulvar vestibule for vulvar vestibulitis. Am J Obstet Gynecol. 1996;74:1701–7.

7

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20. Stewart DB. In: Lawson JB, Stewart DB, eds. Obstetrics and Gynaecology in the Tropics and Developing Countries. London: Arnold; 1967:432.

C o ng e nita l Ano m a lie s o f the G e nita l Tra c t

8

Adam Balen

Intro duc tio n Congenital anomalies of the lower genital tract are often referred to as ‘disorders of sexual development (DSD)’ and encompass both conditions known formerly as ‘intersex conditions’ or variations in the fusion of the Müllerian structures. Disorders of sexual development may result in ambiguous genitalia or anomalies of the internal genital tract and may be due to genetic defects, abnormalities of steroidogenesis and dyssynchrony during organogenesis. The age of presentation will depend upon the degree of dysfunction caused. Ambiguous genitalia occur in approximately 1:30,000 newborns. The rate with which other congenital anomalies present varies depending upon the population studied and the age at which the problem is likely to be noticed. Population-based statistics are still lacking for many conditions—largely because patients present to different specialists (e.g. gynaecologists, paediatric endocrinologists, urologists, etc.) and there are rarely clear pathways for communication between the different professional groups to create a comprehensive service both for provision of treatment and collection of data. In the United Kingdom, the British Society for Paediatric and Adolescent Gynaecology (BritSPAG) has formed networks of specialist care in order to overcome these problems (www.britspag.org). Puberty and adolescence are recognised as periods involving marked endocrine changes that regulate growth and sexual development. The mechanisms which control the precise timing of the onset of puberty, however, are still not clearly understood but are influenced by many factors including general health, nutrition, exercise, genetic influences and socioeconomic conditions. Most of the changes during puberty are gradual, although menarche is a single event that can be dated in girls. Normal puberty involves a fairly regular sequence of events between the ages of 10 and 16 years. A detailed description is beyond the scope of this chapter. In broad terms, once a girl has passed menarche, she is potentially fertile and should be considered as a young woman. The degree of sexual and reproductive maturity is not always mirrored by emotional and psychological maturity and so consideration must be made of the particular needs of adolescent girls when they attend clinics and hospital with gynaecological problems. It is recognised that adolescents with medical problems have special needs. Adolescents with gynaecological problems have

additional needs and require a degree of privacy and sensitive handling. Many of the gynaecological problems encountered relate to intimate bodily functions at a time when the individual is maturing sexually and having to deal with issues that are embarrassing and may be considered taboo. Furthermore, there needs to be consideration made of ethnic and cultural differences and potential problems with communication—particularly as amongst the parents from ethnic minorities it is often the father and not the mother who can speak English. Hence there is a need for interpreters and information written in different languages. Patients with complex disorders of sexual development require sensitive care by an expert multidisciplinary group that includes: gynaecologists, paediatric endocrinologists, paediatric surgeons and urologists, plastic surgeons, psychologists, specialist nurses, geneticists and urologists. A network of support should be provided both to the patient and her parents and family. The adolescent period is a particularly sensitive time as the individual becomes aware of her diagnosis and its impact on her sexuality, sexual function and fertility. It is important to provide a seamless handover from paediatric to adult services at this time and dedicated adolescent clinics have an important role.

Im a g ing The uterus grows in concordance with somatic growth, with differential increased growth of the corpus starting from about the age of 7 years. However, the main differential increase of uterine size compared with somatic growth is obvious only after oestradiol secretion is measurably increased and tends to occur between Tanner breast stage 3 and 4. Awareness of this comparatively late relative increase in uterine size has clinical relevance in the differentiation of arrested puberty and Müllerian agenesis and also in the diagnosis of causes of precocious puberty. Ultrasound is the most suitable imaging technique for the examination of the internal genitalia of girls as it is free from the risks of radiation and involves a quick, quiet and non-invasive procedure. Whilst higher resolution images can be obtained of the ovaries and uterus using transvaginal ultrasonography we can only use the transabdominal approach in young girls and it may not always be possible to visualise both ovaries; furthermore, a full bladder is required. Nonetheless transabdominal ultrasonography is an invaluable tool for the

Section B | Benign Conditions: The Cervix, Vagina and Vulva, Uterus, Ovaries and Fallopian Tubes

8

delineation of normal changes before and through puberty and also the evaluation of paediatric disorders, such as pelvic masses and abnormal pubertal development. As girls go through puberty the ovaries have been described as characteristically becoming multicystic due to low levels of follicle-stimulating hormone stimulating only partial folliculogenesis. The multicystic ovary differs from the polycystic ovary in that the cysts are larger (6–10 mm) and the stroma is of normal echogenicity. The morphological appearance of the multicystic ovary heralds the onset of menstrual activity and may be helpful when planning surgery (or alternatively menstrual suppression with hormone therapy) in cases where obstructed menstruation is anticipated. Whilst ultrasound is usually the first-line imaging modality for the assessment of the pelvis, it is often necessary to get more detailed images in cases of Müllerian dysgenesis - as provided by magnetic resonance imaging (MRI).1 The assistance of a skilled radiologist is required in order to assess the differences between a pre-pubertal, under-developed uterus and a vestigial uterine remnant that will not have the potential to develop. Sometimes serial scans at intervals of 6–12 months (depending upon the child’s age) are required.

La b ia l Ano m a lie s LABIAL ADHESIO N Adhesion of the labia minora is a minor condition commonly seen in young girls under the age of 7 years. It can appear as if the child has no vaginal opening. Usually there are no symptoms, and the vagina may simply look different. Older children may experience discomfort when passing urine or spraying of urine. Sometimes the urine may collect within the lower vagina and the stream of urine may trickle and continue with a postmicturition dribble. Occasionally, a child with labial adhesion may have repeated urinary tract infections or vaginal discharge.

(a)

If the child is asymptomatic no action is required, and the problem is self-correcting with separation of the labia at puberty in response to natural oestrogen production. A pelvic ultrasound to reassure parents that a uterus is present can be very helpful. If there are symptoms, adhesions may be treated using topical oestrogen cream thinly applied to the midline at night over a period of 2–4 weeks.2 It is rarely necessary, or indicated, to resort to surgical separation. Gentle separation under general anaesthetic after a course of topical oestrogen may be performed, but surgical incision through the adherent skin is inadvisable as the consequent scarring may then cause long-term problems. Occasionally, labial adhesion may be associated with lichen sclerosus, which can be confirmed by biopsy and treated by topical steroids.

REDUC TIO N LABIO PLASTY/ LABIAPLASTY Cosmetic vulvovaginal surgery is controversial and whilst this may encompass a number of procedures that are often performed in the private sector under the label ‘vaginal rejuvenation surgery’, here we focus on labial reduction surgery, which is increasingly being requested by adolescent girls and young women. There are, however, wide natural variations in vaginal, labial and clitoral dimensions, positions, symmetry and rugosity.3 When the labia majora are thin, which can be related to body fat distribution, the labia minora may appear more prominent; whereas when the labia minora are smaller, the clitoris and introitus may appear more prominent. Overall impressions will be affected by the volume, texture and pigmentation of adjacent body tissue. A number of different techniques have been described, ranging from the simple ‘trimming’ of the edge of the labia minora, the edge of which is then sutured (Fig. 8.1). This is a less satisfactory method as a scarred labial edge remains which may be cosmetically unsatisfactory.

(b) Fig. 8.1: Labial trimming.

104

Congenital Anomalies of the Genital Tract

8

(a)

(b) 8.2: Labial wedge resection.

An aesthetically and cosmetically preferable procedure is to remove a triangular wedge in order to preserve the labial edge, preserving the nerves and reducing the risk of hypopigmentation of the scar line (Fig. 8.2).4 One large retrospective series of 407 women reported a 4.4% rate of significant complications including revision.5 It has also been suggested that the appearance of pre-pubescent labia, commonly represented in pornographic imagery, is often considered the ideal by women seeking genital cosmetic surgery.6 A detailed study of 17 women found that the main reason they requested surgery was because they viewed their pre-surgery appearance as ‘defective’ and sought a ‘normal’ genital look.7 The women tended to base their view of ‘normal’ on social norms projected in the media that female genitalia should be ‘invisible’, with no protruding labia, and they requested the operation because they found their situation stigmatising. The study also highlighted that health professionals are delivering mixed messages about what is ‘normal’. The women’s perception of being ‘abnormal’ was inadvertently reinforced by being given reassurance of normality, alongside referral to a specialist for further investigation or surgical intervention. Another common theme was that the women felt their appearance impacted negatively on their sex lives and relationships. Although the operation did have the effect of making the women less self-conscious, expectations of improved sex-life and relationships were not met for all women. There is significant concern about the practice of female genital cosmetic surgery8,9 as expressed by position statements from both the American and British Colleges.10,11 In its statement the Royal College of Obstetricians and Gynaecologists (RCOG) indicates its concern ‘that requests for labioplasty surgery may be made by women who do not realise that the appearance of the external genitalia varies from one woman to another. Furthermore, there is the potential for a woman to be

harmed by these procedures, with very little scientific evidence regarding their benefits’.

C o ng e nita l Ute rine Ano m a lie s In the absence of a Y chromosome, testis and testosterone, the Wolffian duct regresses after the 6th week of embryonic life. The Müllerian ducts then develop into the uterus and Fallopian tubes and fuse caudally with the urogenital sinus to form the vagina. Abnormalities in the process of fusion may be either transverse or vertical and result in primary amenorrhoea; complete or partial Müllerian agenesis may also occur. Renal developmental abnormalities are commonly seen in association with abnormalities of the genital tract so assessment by appropriate imaging (usually ultrasound or MRI) is advisable before attempting corrective surgery.

C LASSIFIC ATIO N O F MÜLLERIAN ANO MALIES Uterine anomalies occur in between 3% and 10% of the fertile female population. The more common anomalies have been reported in 2–3% of fertile women, 3% of infertile women and 5–10% of those with recurrent miscarriage.12 Uterine anomalies can be subdivided according to the nature of the abnormality and were originally classified by the American Fertility Society [AFS, now the American Society for Reproductive Medicine (ASRM)] into seven groups (Fig. 8.3)13: 1. Segmental agenesis or hypoplasia – which may involve vagina, cervix, uterine corpus or Fallopian tubes. Mayer– Rokitansky–Kuster–Hauser syndrome is included here. 2. Unicornuate uterus, with or without a rudimentary horn that may or may not contain endometrium and be connected to the main uterine cavity. On the affected side the kidney and ureter are generally absent. 105

Section B | Benign Conditions: The Cervix, Vagina and Vulva, Uterus, Ovaries and Fallopian Tubes 3. Uterus didelphys: due to partial or complete failure of lateral Müllerian duct fusion leading to partial or complete duplication of the vagina, cervix and uterus.

4. Bicornuate uterus: with a single vagina and cervix and two uterine bodies that may be completely separated or fused centrally with a partial septum.

2. Unicornuate

1. Hypoplasia/agenesis

8 (a) Vaginal

(b) Cervical

(c) Fundal

(d)Tubal

(e) Combined

(a) Communicating with rudimentary horn

(b) Non-communicating with rudimentary horn

(c) No cavity

(d) No horn

4. Bi-cornuate

3. Didelphys

(a) Complete

5. Septate

6. Arcuate

(a) Complete

(b) Partial

7. DES drug related

Fig. 8.3: American Fertility Society (AFS) classification of uterine anomalies.

106

(b) Partial

Congenital Anomalies of the Genital Tract 5. Septate uterus, with a septum that may be partial or complete. 6. Arcuate uterus, with a mild indentation at the level of the fundus. 7. Diethylstilbestrol-related anomalies, which might demonstrate various shapes (often ‘T-shaped’) due to the effect of diethylstilbestrol, which was administered to prevent recurrent miscarriage in the 1950s and whose effects are still observed, although in fewer cases as time goes on. It is important to remember the common association between unilateral uterine dysgenesis and ipsilateral aplasia of the renal tract. The AFS classification is simple and concentrates predominantly on the description of the uterine malformations. There have been further attempts to extend the AFS classification with the recognition of additional complex malformations.14 Indeed case reports of previously undescribed anomalies continue to be published. To this end a more comprehensive classification has been proposed, which subdivides the anomalies based upon precise organ subgroups together with associated malformations, which are present in up to 30% of cases. This is the VCUAM (Vagina Cervix Uterus Adnexa – associated Malformation) classification (Table 8.1)15: The VCUAM classification is complex and difficult to memorise. Furthermore it has been criticised because there is no attempt to weight the severity of each of the anatomical variants, which are therefore given the same importance. There are therefore proposals to further enhance the system for classification. Women with uterine anomalies are usually asymptomatic, unless there is obstruction to menstrual flow, when cyclical pain may be experienced. Whilst infertility per-se is rarely caused by uterine anomalies, they may be associated with endometriosis if there is retrograde menstruation secondary to obstruction. Furthermore recurrent miscarriage may be experienced by some women with uterine malformations. Uterine anomalies may present with painful menstruation due to partial obstruction of a hemi-uterus but are often discovered by chance during investigations for infertility. The diagnosis is made by a combination of ultrasound (nowadays often 3-D or 4-D), magnetic resonance imaging and X-ray hysterosalpingography (the latter during the course of an infertility work up). Surgery is reserved for those cases where there is obstruction, for example, the removal of a rudimentary uterine horn or excision of a vaginal septum. The excision of a uterine septum has also been shown to improve pregnancy outcome and should be performed by an experienced hysteroscopist. On the other hand, metroplasty (Strassman procedure) of the horns of a bicornuate uterus is seldom performed nowadays as its benefit has been questioned.

VAG INAL AG ENESIS Women with Mayer–Rokitansky–Kuster–Hauser syndrome (MRKH or Rokitansky syndrome) have a 46,XX genotype and a normal female phenotype with spontaneous development of

Table 8.1: The VCUAM (Vagina Cervix Uterus Adnexa-associated Malformation) classification Vagina (V)

Cervix (C)

Uterus (U)

0

Normal

1a

Partial hymenal atresia

1b

Complete hymenal atresia

2a

Incomplete septate vagina 40 kg/m2)

2.0

Age >80 years

1.9

Emergency procedure

1.8

Pre-operative functional status

1.8

Current smoker

1.5

Diabetes mellitus

1.5

Surgical complication rates are inherently difficult to quantify. Comparison is hampered by the variety of definitions and classification systems for complications reported in the literature. Many studies look retrospectively at nationally collected statistics. This allows for large datasets, but is likely to represent underreported complications. Even large, multicentre, randomised controlled trials will undoubtedly be subject to a degree of either over- or under-reporting bias. When considering generic statistics, it is important to remember that complication rates will depend on a number of factors including the individual surgeon, experience level of theatre staff, anaesthetic factors, the patient’s pathology, age and co-morbidities, and the standard of postoperative care. As with all surgery, careful pre-operative selection of patients is crucial to minimise complications. Historically, two personal series of 1000 cases, together with data from a collaborative study provided the “bench mark” for the morbidity and mortality of hysterectomy for benign conditions.79,80 Dicker produced further data on complication rates,81,82 but since then many new studies have been undertaken. Indications for hysterectomy, surgical practices and available antibiotics are just a few of the many contributory factors affecting complication rates, which have changed dramatically in the last half century. It is therefore reasonable to consider the most up-to-date, robust published data when discussing surgical complication rates. In the US, a recent analysis of 22,214 women undergoing major gynaecological procedures for both benign and malignant pathology quoted an overall 30 day postoperative major complication rate of 3.7%. Predictors of major postoperative morbidity after benign gynaecological surgery included increased operative time, medical comorbidities and pre-operative dependent functional status (see Table 9.10).83 In contrast, NICE published data based on long-term cohort studies describing major operative complication rates at 3.1%

for vaginal, 3.6% for abdominal and 6.1% for laparoscopic hysterectomy, with major postoperative complications of 1.2% for vaginal, 0.9% for abdominal and 1.7% for laparoscopic hysterectomy.29 Specific complications include vascular, bowel and urinary tract injury, and a need to convert from vaginal or laparoscopic to open surgery (see Table 9.11).29 Increasingly, studies are showing similar complication profiles between abdominal and laparoscopic hysterectomy, which may reflect increasing experience in the laparoscopic procedure.84,85 Outcome from visceral injury relies on intra-operative recognition and repair. Unrecognised bowel, ureter or bladder injury can result in sepsis or fistula formation, commonly entero-vaginal or vesicovaginal. Ligation or transection of the ureter can result in unilateral loss of kidney function. It should be reiterated that the course of the ureter should be carefully assessed during surgery. Ureteric injury can occur at the level of the infundibulopelvic ligament, the uterine artery pedicle, the uterosacral ligament and the vaginal angle. Ureteric injury most commonly occurs in the distal 3 cm portion closest to the cervix. Complications specific to laparoscopic entry are discussed in Chapter 3 and 6. Urinary outflow tract dysfunction can be a long-term complication of hysterectomy. The uterus is closely related to the bladder and the pelvic plexus, which provides autonomic innervation to the pelvis. The pelvic plexus is more at risk during total hysterectomy, either during division of the cardinal ligaments, dissection of the bladder from the uterus and cervix, paravaginal dissection or during removal of the cervix. Almost universally, radical hysterectomy involves neural bladder damage. In contrast, hysterectomy for benign conditions is associated with a spectrum of symptoms postoperatively, in keeping with inconsistent damage to the pelvic plexus. The evidence for postoperative bladder dysfunction after hysterectomy remains inconclusive, with both positive and negative effects being demonstrated. Urinary symptoms are prevalent in women undergoing hysterectomy, and it is likely that preoperative status will go some way to governing postoperative symptoms. One advantage of observational studies over randomised controlled trials is the increased availability of long-term outcome data, which allows for urinary function outcomes to be assessed (see Table 9.12). Lesser complications include postoperative urinary retention and urinary tract infection. In theory, reduced postoperative pain and early mobilisation should reduce the incidence of acute retention. Prophylactic antibiotics, scrupulous aseptic technique and shorter duration of catheterisation will all reduce the incidence of urinary tract infection. In addition to the more common complications already discussed, numerous immediate and delayed complications have been described (see Table 9.13).

9

O UTC O ME MEASURES All forms of hysterectomy should ideally result in complete amenorrhoea. Very occasionally, cyclical “staining” may occur 175

Section B | Benign Conditions: The Cervix, Vagina and Vulva, Uterus, Ovaries and Fallopian Tubes Table 9.11: Complication rates for hysterectomy (as described by NICE Heavy Menstrual Bleeding Guideline29 using data from randomised controlled trials in a Cochrane review35) Complication

9

Blood transfusion Bowel injury Vascular injury Pelvic haematoma Vaginal cuff infection Abdominal wound infection Laparotomy Urinary tract injury (bladder/ureter) Bleeding Urinary tract infection Chest infection Unspecified infection Thromboembolism

Abdominal hysterectomy (%)

Vaginal hysterectomy (%)

Laparoscopic hysterectomy (%)

3.33 0.67 0.77 6.00 2.06 7.38

3.87 0.00 0.94 4.04 1.93 0.00

4.23 0.20 1.81 3.94 4.15 1.92

--0.86

2.66 1.60

4.17 2.33

1.57 4.87 4.55 13.15 0.00

0.00 1.60 6.67 7.73 0.00

0.37 4.77 0.56 10.01 0.59

from endometrium in the cervical stump. The outcome measures for comparison are not exhaustive, but include: 1. Immediate morbidity, length of hospitalisation and time to full recovery. 2. Major complication rate, haemorrhage, sepsis, visceral injury and other complications. 3. Impact upon coitus, micturition and defaecation; especially the occurrence of new symptoms following surgery. 4. The occurrence of post-hysterectomy genital prolapse. 5. Cost of procedure and hospital admission/follow-up. 6. Quality of life.

C O NC LUSIO N

Ute rine Fib ro ids a nd The ir Tre a tm e nt Uterine fibroids are benign smooth muscle tumours (leiomyomas). They are common, occurring in up to 1:4 women of reproductive age, but typically regress spontaneously after the menopause. Many fibroids are asymptomatic, often detected incidentally during routine examination or on imaging. In such cases, patients do not need treatment and should be reassured. It has been estimated that between 20% and 50% of women with fibroids will present with symptoms, which will depend on their number, size and position. Fibroids can occur in any part of the uterus and can be found in the cervix or in the broad ligament, or parasitised to other organs.88–90 Clinical manifestations of fibroids include heavy menstrual bleeding, pressure on the bladder or gastro-intestinal tract, increased abdominal girth, pain and subfertility (see Table 9.14). The role of fibroids in miscarriage and pre-term delivery is more controversial. Pain can be associated with fibroid degeneration (often in pregnancy), torsion of a pedunculated fibroid or extrusion of a submucous fibroid through the cervix. Surgery is indicated to control symptoms that are having a significant impact on quality of life, to relieve hydronephrosis due to ureteric compression or in suspected cases of uterine sarcoma where the ‘fibroid’ is growing rapidly. This diagnosis should be particularly considered in the presence of a rapidly growing painful fibroid and is more common in post-menopausal women (see Chapter 16).

THERAPEUTIC O PTIO NS

Hysterectomy where indicated is a safe and effective operation with high patient satisfaction rates. In principle, vaginal hysterectomy should be the first choice of route if it is clinically feasible. Laparoscopic hysterectomy has a relatively long learning curve, but more recent published data and the authors’ experience suggest that in experienced hands, the laparoscopic approach is no longer associated with the higher complication rates published during its infancy.33–37,84,85 Quicker recovery rates following the laparoscopic and vaginal approaches provide

Table 9.12:

a clear advantage over the abdominal approach, but the surgeon’s own experience and ability are of paramount importance when considering the appropriate type of hysterectomy.

GnRH Analogues Gonadotrophin-releasing hormone analogues (GnRHa) cause hypo-oestrogenism, which leads to a 40–60% reduction in uterine volume and fibroid size, and transient amenorrhoea. The maximal effect occurs within 3 months of treatment, although it may be continued for a total of 6 months as a primary treatment of symptomatic myomas, or as an adjunct to surgical treatment. Associated transient menopausal symptoms

Urinary symptoms reported by long-term cohort studies29

Complication

Abdominal hysterectomy

Vaginal hysterectomy

Laparoscopic hysterectomy

Urinary incontinence

Moderate (OR) Severe (OR)

1.19 (1.00–1.41) 1.52 (1.20–1.93)

1.30 (1.15–1.46) 1.59 (1.34–1.89)

1.82 (1.28–2.59) 2.02 (1.32–3.07)

Urinary frequency

Moderate (OR) Severe (OR)

1.28 (1.08–1.52) 1.51 (1.20–1.90)

1.10 (0.97–1.23) 1.15 (0.96–1.37)

1.03 (0.74–1.43) 1.33 (0.85–2.07)

Nocturia

Moderate (OR) Severe (OR)

1.34 (1.06–1.69) 1.33 (1.08–1.64)

1.19 (1.01–1.39) 1.17 (1.00–1.36)

1.03 (0.68–1.57) 0.90 (0.57–1.41)

Odds Ratios (ORs) calculated against general population. All ranges are 95% confidence intervals.

176

The Uterus Table 9.13: Less frequent and longer term complications of hysterectomy29,82,83,85–87 Genital tract complications

Gastrointestinal complications

Vault prolapse Incisional hernia at vaginal apex Eversion of vagina Vaginal vault dehiscence Prolapsed Fallopian tube Foreign body granuloma Residual ovarian syndrome Ectopic pregnancy Adnexal abscess Consort glans laceration

Necrotising colitis Constipation Irritable bowel syndrome Bowel obstruction Colo-vaginal fistula Sigmoido-vesical fistula Perforation of duodenal ulcer

Urinary tract complications

Other complications

Ureteric fistula Salpingo-vesical fistula Hydronephrosis Chronic renal failure Wissler-Fanconi syndrome Incisional bladder hernia

Sexual difficulties Recurrent pneumoperitoneum Femoral neuropathy Premature ovarian failure Ischaemic heart disease Osteoporosis

can be alleviated with addback HRT, although this may also render the fibroid shrinkage less effective. Longer GnRHa treatment carries a significant risk of osteoporosis and is not recommended. Once therapy stops, fibroids soon return to their previous size over several months. Consequently primary treatment is rarely undertaken, and the role of GnRHa is limited to volume reduction and correction of anaemia prior to surgery. Rarely, medical treatment with GnRHa therapy may be considered in perimenopausal women in an attempt to avoid surgery until the menopause is reached, or for patients in whom other treatments have failed and surgery is contraindicated.91 Women who continue to have significant symptoms in spite of 3 months of medical therapy or whose fibroids show no sign of shrinkage should not normally be considered for conservative management. There is a remote risk of unrecognised leiomyosarcoma. Progress of medical therapy may be monitored by symptoms, examination or by ultrasound or in some cases MRI imaging.92

Table 9.14:

Clinical manifestations of fibroids

Heavy/prolonged menstrual bleeding Anaemia Increased abdominal girth Pelvic mass Pressure symptoms Urinary frequency Urinary outflow obstruction Ureteric compression (hydronephrosis) Constipation Tenesmus Bowel obstruction (rare) Pelvic or lower limb deep vein thrombosis Recurrent pregnancy loss

Pre-term labour Subfertility Tubal obstruction or distortion Distortion of endometrial cavity Altered location of cervix/ uterine size Pelvic/abdominal pain Fibroid degeneration Torsion (pedunculated fibroids) Cervical extrusion (submucous fibroids) Dysmenorrhoea Dyspareunia Malignant transformation (rare) Ascites or polycythaemia (rare)

Other Hormonal Therapies Progestogens have been reported to reduce the growth of fibroids, and mifepristone (an antiprogesterone) has also been shown to reduce fibroid size. They are less beneficial than GnRHa however, and the authors rarely use either in clinical practice. A newer selective progesterone receptor modulator is now available, which has shown some promise as a medical therapy in achieving fibroid shrinkage. This appears to have advantages compared to GnRHa treatment in terms of sideeffect profile, and early studies suggest persistence of fibroid shrinkage following cessation of treatment. Currently it is licensed in the UK for pre-operative treatment of fibroids only. In cases where the main symptom of the fibroids is heavy menstrual bleeding, progestogens can limit menstrual blood flow and hence preclude the need for treating the fibroids themselves.

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Laparoscopic and MRI-Guided Myolysis Myolysis involves the internal coagulation of targeted fibroids to destroy the stroma and the associated vascular supply resulting in degeneration and shrinkage. The method used may be laser, electrocoagulation or hypothermia (cryomyolysis).93–95 There is a greater risk of uterine rupture in pregnancy following myolysis, due to devascularisation of adjacent myometrial tissue, and the procedure has been associated with dense adhesion formation in some cases. Consequently it is a less common method of treatment, and is not advisable for women wanting to conceive.96

Uterine Artery Embolisation (UAE) This minimally invasive technique was originally devised to control bleeding in massive postpartum haemorrhage, but has since been employed to treat symptomatic uterine fibroids. Non-biodegradable particulate emboli (typically polyvinyl alcohol [PVA] or trisacryl gelatin spheres) are delivered to both uterine arteries via percutaneous catheterisation of one of the femoral arteries under angiographic guidance. The uterine vessels are occluded bilaterally, causing ischaemic necrosis of the uterine fibroids.97 This causes a reduction in fibroid volume of 30–50%. It is usually a day-case or overnight-stay procedure. There is commonly significant post-procedure pain (comparable to “red degeneration” in pregnancy), and serious complications from uterine infarction followed by infection have been reported.98–101 The risk of this is less than 1%, although severe sepsis may warrant hysterectomy, and fatalities have been reported.102 Other risks include premature ovarian failure in 1–2% of patients and secondary amenorrhoea.98,101 Recent long-term follow-up data comparing UAE with surgery (hysterectomy or myomectomy) showed equally improved quality of life scores at 5 years in both groups; however, UAE carried a 32% re-intervention rate, which neutralised its initial cost benefit.103 Although normal uterine myometrium preferentially establishes a new collateral blood supply from vaginal and ovarian

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vessels, there are concerns about subsequent pregnancy following UAE. Miscarriage rates are higher and uterine rupture in labour has been described. The altered uterine blood supply could theoretically impact on placentation, causing intra-uterine growth restriction. Premature labour, postpartum haemorrhage, Caesarean section and malpresentation are all more common after UAE.98,104,105 In essence, whilst UAE is an effective non-surgical treatment for symptomatic fibroids, it should be used with great caution in women who wish to conceive in the future.

MRI-Guided Focused Ultrasound This is a non-invasive procedure, which involves the treatment of fibroids with a focused beam of high-frequency ultrasound under MRI guidance. Resulting localised thermal energy causes coagulative necrosis of individual fibroids and hence a reduction in fibroid volume. Patients are thought to experience less pain than with the ischaemic effects of UAE, and the procedure has an excellent safety profile. Potentially this therapy will have an application as a non-surgical treatment that preserves reproductive capacity. The treatment is not yet widely available, and long-term comparative data are awaited.

Herbal Remedies In 2010, a Cochrane review researched the evidence for traditional herbal remedies in the treatment of fibroids. It concluded that current evidence does not support their use due to the limited number of trials and their insufficient methodological quality, and it called for large good quality studies.106

Myomectomy Whilst the definitive surgical treatment for symptomatic fibroids is hysterectomy, many women desire relief of symptoms but wish to conserve their uterus, often to retain or improve their reproductive potential, or to adhere to their cultural or social views. For these women, myomectomy is an important option.

Hysterectomy Hysterectomy is discussed in detail earlier in the chapter, and remains a surgical alternative to myomectomy if ongoing fertility is not desired. Advantages over myomectomy include amenorrhoea and preventing recurrence of fibroids. Hysterectomy would normally be preferred to myomectomy in women who have completed their family as it is widely accepted to be associated with lower peri-operative morbidity and is definitive. Myomectomy may cause adhesion formation between the uterus and the small or large bowel, which can render subsequent pelvic surgery (e.g. repeat myomectomy or hysterectomy) more complex. 178

Myo m e c to m y Myomectomy is defined as the enucleation of uterine fibroids with reconstruction and preservation of the uterus, in an effort to maintain its function. Successful abdominal myomectomy was first described in 1845 by Atlee, prior to the development of abdominal hysterectomy.107 It is a less common surgical treatment than hysterectomy, with approximately 35,000 abdominal myomectomies performed each year in the USA, compared with 600,000 hysterectomies. It is widely accepted that myomectomy is associated with a higher rate of blood transfusion, postoperative anaemia, febrile morbidity, and possibly an increased risk of paralytic ileus and longer length of stay.89 Recent literature suggests that with improved access to blood transfusion and the widespread use of prophylactic antibiotics, morbidity and length of hospital stay following abdominal myomectomy is comparable to abdominal hysterectomy.108 Selection bias may govern procedure choice and hence outcomes of comparative studies however. Arguably, in cases where operative difficulty is anticipated (e.g. previous myomectomy or women with multiple fibroids), patients may have been preferentially advised towards hysterectomy. Further prospective studies are needed. Fibroids can be surgically removed at laparotomy, laparoscopy, by vaginal myomectomy or, in the case of submucous fibroids, by hysteroscopic resection (see ‘Transcervical Resection of Fibroids’). The major advances in laparoscopic equipment of recent years, together with refinements in technique, allow effective and efficient haemostasis, suturing and tissue removal. Consequently, the limits of laparoscopic myomectomy in relation to fibroid size, location and number are continuing to be challenged. In women with abnormal bleeding, preliminary diagnostic hysteroscopy is generally indicated to exclude submucosal fibroids or an endometrial lesion.

REDUC ING SURG IC AL RISKS

Operative Blood Loss A number of techniques have been described to overcome the problem of haemorrhage during open myomectomy.109–112 Some techniques can also be applied to the laparoscopic approach, and indeed laparoscopic myomectomy itself is associated with only a 2% transfusion rate compared with 20% at abdominal myomectomy. This may reflect patient selection however.113 Blood loss can occur intra- or postoperatively and be associated with formation of a haematoma. Myomectomy for huge fibroids can be associated with massive blood loss, which can warrant blood transfusion and intra-operative conversion from laparoscopic to open myomectomy, or conversion from open myomectomy to hysterectomy. Techniques to reduce blood loss can be broadly divided into four categories (see Table 9.15). By causing amenorrhoea, pre-operative GnRHa treatment allows optimisation of haemoglobin levels in patients suffering

The Uterus Table 9.15: Interventions to reduce blood loss at myomectomy Interventions on uterine blood supply

Uterotonics

• Laparoscopic uterine artery dissection • Intramyometrial vasopressin • Uterine artery +/- ovarian artery tourniquet or clamp • Intramyometrial bupivacaine with adrenaline • Pre-operative GnRH analogues • Pre-operative uterine artery embolisation

• Misoprostol Dissection techniques • Mesna (lytic agent facilitating enucleation) • Laparoscopic myomectomy • Cutting diathermy for uterine incisions Antifibrinolytics • Tranexamic acid

with menorrhagia. Pre-treatment also reduces operative blood loss due to its effect on uterine vascularisation. Fibroid shrinkage can allow massive fibroids to be approached via a Pfannenstiel rather than a midline incision, or even laparoscopically or vaginally. Operating time may be reduced at hysteroscopic resection but not at myomectomy. Some surgeons describe adherent, fibrotic tissue planes around myomas after GnRHa, although this has not been confirmed by clinical studies. Postoperative complication rates are not affected by GnRHa, although there is a small reduction in postoperative stay.112 There is no benefit from using oxytocin during myomectomy, which is consistent with the fact that there are few myometrial oxytocin receptors outside of pregnancy. Likewise myoma enucleation by morcellation has no effect on intraoperative blood loss. Other alternatives that have not been formally assessed by clinical trials include pre-operative UAE, ergometrine and the use of cutting diathermy to dissect out the myoma. The most effective intervention appears to be occlusion of the uterine and ovarian arteries, which in one small prospective study of 28 patients showed a significant reduction in mean blood loss compared with control, making it difficult to justify not using tourniquets. The study demonstrated a significant reduction in transfusion rate from 79% to 7%, with no apparent effects on uterine perfusion or ovarian function.111 It is common knowledge amongst gynaecologists that rarely, massive haemorrhage can complicate myomectomy. It is therefore important when considering myomectomy to discuss with the patient the rare but appreciable risk of resorting to hysterectomy intra-operatively in cases of uncontrollable, life-threatening bleeding.

Adhesion Prevention Postoperative adhesions are common following myomectomy, affecting 59% of women 2 years after open myomectomy.114 They are particularly important in the context of surgical treatment for subfertility. Small bowel adhesions onto the site of the uterine incision can be dense. Adhesions have been associated with small bowel obstruction, chronic abdominal

pain, dyspareunia and subfertility115,116 and can impact on the feasibility of subsequent pelvic surgery, including repeat myomectomy, hysterectomy or even Caesarean section. Posterior uterine wall incisions are associated with a higher rate of adnexal adhesion formation than fundal or anterior wall incisions, and second-look laparoscopy has been advocated by some surgeons in the past for secondary adhesiolysis.117 Adhesion formation has been shown to be less common following laparoscopic procedures compared to laparotomy.118 Adhesion prevention may be due to factors such as meticulous haemostasis, evacuation of blood clot from the pelvis and less tissue handling and drying. These factors are all more readily achieved laparoscopically. There is no evidence that these factors apply to adhesion reduction in laparoscopic myomectomy, although comparative data with open myomectomy are limited.113 Whilst it is accepted that fertility outcome after myomectomy is improved,119 it is logical to take any precautions available to reduce adhesion formation. Adhesion barriers have been explored for this reason. Omental or peritoneal grafts have been described. These have the advantage of being natural and cheap, although there is no evidence of benefit. They may interfere with ovulation or oocyte transfer, and need to be sutured into place, which increases operative time. This can be especially disadvantageous during laparoscopic procedures. Several synthetic adhesion barrier agents are available that are designed to provide an inert barrier between damaged serosal surfaces for at least 72 hours, in order to prevent unwanted mesothelial regeneration and fibrosis. Again evidence for their efficacy is limited and their cost must be considered, but they have the advantage of being safe and quick to apply.116 It is the authors’ preference to use synthetic adhesion barriers during laparoscopic and open myomectomy.

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O PEN VERSUS LAPARO SC O PIC MYO MEC TO MY There has been little change to the technique of open myomectomy popularised by Bonney in the 1930s.120,121 Surgical principles of myomectomy are to minimise intraoperative blood loss, reduce postoperative adhesion formation and achieve adequate myometrial repair and closure to allow the uterus to withstand pregnancy and possibly labour. Laparoscopic myomectomy requires meticulous repair of the myometrium, which can be technically difficult. It should only be attempted by experienced laparoscopic surgeons. With advances in laparoscopic instruments and experience in the techniques required to achieve safe removal of large fibroids including multilayer closure of large myometrial defects, evidence for the benefits of laparoscopic myomectomy is growing. Recent meta-analysis has shown that the laparoscopic approach is associated with a shorter hospital stay, faster recovery, less adhesions, less blood loss and fewer overall postoperative complications in the hands of skilled surgeons.122 Mean operative time is comparable, and there is no difference 179

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in the subsequent pregnancy rate, miscarriage rate, ectopic pregnancy rate, preterm delivery or Caesarean section rate between open and laparoscopic groups.119,123 Meta-analysis has shown no evidence of benefit of pre-operative GnRHa and no difference in recurrence rates compared with open myomectomy. Indeed, whilst pre-operative GnRHa therapy results in a 40–60% reduction in uterine volume within 12 weeks of treatment, the effects on fibroid size and vascularity may paradoxically make dissection of the fibroid from its pseudocapsule more difficult. This could lead to increased operative time. With appropriate myometrial closure, the risk of uterine rupture is low and pregnancy outcomes have been good.122,124 Appropriate patient selection is important: uterine size and mobility, fibroid size and location and previous surgery must all be considered when deciding on route of myomectomy. The main limitation of laparoscopic surgery is the relatively long learning curve required to achieve complex surgery safely. Some surgeons rely on robotic-assisted laparoscopic surgery for this reason, and whilst robotic surgery carries the obvious limitations of increased abdominal port size, longer operating times and considerable cost, there is evidence to suggest that in terms of operative blood loss and length of hospital stay, robotic myomectomy is similar to conventional laparoscopic myomectomy. Both are associated with decreased surgical blood loss and reduced length of hospital stay when compared with open myomectomy.125,126

Open Abdominal Myomectomy

Fig. 9.85: Open myomectomy. Bonney’s myomectomy clamp is being applied to the cervix in order to occlude the uterine vessels. A rubber-guarded bowel clamp has been applied to each infundibulopelvic ligament to control the ovarian vessels. This technique can result in an almost bloodless uterine incision.

A careful assessment of the size and mobility of the uterus should be made under anaesthetic prior to deciding between a midline or Pfannenstiel incision. After abdominal entry, a careful assessment of the location, size and number of the fibroids present is made. The tubes and ovaries are also inspected. In cases of significant anatomical distortion due to large or multiple fibroids, the Fallopian tubes and round ligaments provide useful uterine landmarks and act as a guide to locating the endometrial cavity and planning the incision, or incisions, on the uterus. Temporary haemostasis of the surgical field may be obtained by the use of Bonney’s myomectomy clamp (Fig. 9.85) applied to the uterine vessels and by guarded bowel clamps or loose ties to the infundibulopelvic ligaments. Alternatively, a rubber catheter may be tied as a haemostatic sling around the cervix (Fig. 9.86). As described earlier, injection of 20 ml of vasopressin (0.05 U/ml) over the site of the uterine incision has also been shown to reduce haemorrhage. The uterus is delivered through the incision, and the fibroids are inspected to assess the best and safest incisional approach for enucleation without compromising the Fallopian tubes, the endometrial cavity or the ovarian or uterine vessels. In the case of individual fibroids, a primary uterine incision should be made down to the tumour. As soon as the pseudocapsule of the fibroid is reached, the uterine incision opens up by retraction and it is usually possible to find a natural plane of

cleavage between the tumour and normal myometrium. The actual enucleation can be carried out digitally or by blunt dissection (Fig. 9.87) with a slightly curved instrument such as a pair of curved Mayo scissors. Often, the most useful incision in the uterus is on the anterior surface. This allows anterior fibroids to be removed first, hence debulking the uterus and improving access to other parts of it. It is possible to use an anterior incision to approach posterior fibroids through the uterine cavity, enucleating them from the posterior wall of the myometrium without making a separate incision on the posterior peritoneal surface of the uterus (Fig. 9.88). This is a so-called transcavity myomectomy. One advantage of the transcavity approach is that it enables the surgeon to explore the endometrial cavity for submucous fibroids if desired. Where possible, posterior incisions are avoided due to the greater risk of bowel adhesions and a subsequent risk of obstruction. Bowel adhesions can also necessitate difficult dissection during future pelvic surgery. Entering the endometrial cavity carries the obvious risk of Asherman’s syndrome however, and could theoretically lead to adenomyosis. It is therefore important to consider the patient’s future fertility intentions and other abdominal or pelvic pathology when planning the uterine incision.

O PERATIVE TEC HNIQ UES

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The Uterus In certain cases (e.g. in case of a posterior pedunculated subserous fibroid), a posterior uterine incision is unavoidable (Fig. 9.89). In the past, some surgeons advocated tacking a small omental graft over the posterior uterine incision in order to prevent the small bowel from adhering to the uterus.

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Fig. 9.86: Open myomectomy. This illustration shows the rubber tourniquet method (e.g. a urinary catheter) for controlling the uterine vessels. The ovarian vessels have to be compressed separately with intestinal clamps. The dotted line shows one method of making a peritoneal flap. Fig. 9.88: Open transcavity myomectomy. The anterior uterine wall has been transected and the endometrial cavity entered. An incision is being made in the posterior uterine wall in order to enucleate any fibroids in the posterior wall.

Fig. 9.87: Open myomectomy. The uterus has been incised and the fibroid grasped by a Vulsellum forceps. It is being enucleated from its pseudocapsule by the handle of a scalpel. This is an intramural, postero-fundal fibroid.

Fig. 9.89: Open myomectomy. Multiple uterine incisions to approach fibroids in different locations.

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Alternative and more conventional approaches to reducing the risk of adhesions include careful, atraumatic surgical technique and suturing, minimising blood loss, preventing tissues from becoming dry during surgery, careful closure of the uterine serosa to ensure no myometrium is exposed, and as described later, artificial adhesion barriers such as “Interceed” (Ethicon), which can be placed over the uterine incisions to prevent adhesion formation. In order to minimise the danger of bowel adhesion to the uterus and to ensure proper peritonisation, Bonney described the ‘hood’ operation.120 In this method, a transverse incision is made across the capsule of the fibroid as low down and as anteriorly as possible. After enucleation of the fibroid, the capsule is trimmed of its redundant myometrium and sewn over the uterus so that the apex of its lower end lies in the uterovesical space (Figs. 9.90, 9.91). Another potentially useful manoeuvre to limit the size of the primary uterine incision is to morcellate the fibroid in vivo. This can be associated with more bleeding however. If the uterus contains a large number of fibroids and individual enucleation is impractical, it is sometimes feasible to remove a block of the uterus containing the bulk of the fibroids en masse. Another useful technique is hemisection of the anterior or posterior myometrium, allowing access to centrally placed fibroids, and then enucleating any further fibroids remaining in each half by lateral tunnelling (Fig. 9.92). Finally, the uterus can be reconstructed by suturing the two halves together in the midline. Fibroids may be encountered in a number of different locations, including anterior, posterior, fundal, cervical, broad ligament or submucosal sites. These types may occur alone or

Fig. 9.91: Open myomectomy. Bonney’s ‘hood’ operation. The peritoneum is being sewn over the anterior surface of the uterus.

Fig. 9.92: Open myomectomy. The technique of lateral tunneling, by which the surgeon employs a primary incision in the anterior uterine wall and extends the dissection laterally to enucleate fibroids lying on either side of the primary incision.

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Fig. 9.90: Open myomectomy. Bonney’s ‘hood’ operation. The fibroid has been enucleated and the resulting dead space is being obliterated with sutures.

together as multiple masses, and each demands certain modifications of technique, with a view to normalising the uterine anatomy as much as possible. In planning the primary incision on the uterus, transverse incisions may be preferable to vertical, because the arteries and

The Uterus arterioles of the myometrium run transversely.127 The ideal position is one comparable to that used in lower segment Caesarean section because, when the myomectomy is complete, the loose peritoneum of the uterovesical pouch can be used to completely cover the uterine scar. It is, however, important not to fix the bladder too high up on the front of the uterus, as this could complicate reflection of the bladder in a subsequent Caesarean section or hysterectomy. The flap method illustrated in Figures 9.93 to 9.96 can also be useful. In the case illustrated, the base of the flap is situated at the fundus. When all apparent fibroids have been removed, the myometrium is systematically palpated for residual fibroids prior to closure. The enucleated fibroid cavities must be carefully explored and thoroughly obliterated by absorbable, No. 1 polyglycolic acid sutures. These are passed through the full thickness of the myometrium on each side of the myometrial defect and tied so that no dead space remains (Fig. 9.97) and haemostasis is achieved. Approximating the tissues of the defect reduces the real chance of postoperative bleeding into the dead space, which can result in a significant haemoglobin drop, postoperative pyrexia and infection, and the risk of a postoperative haemoperitoneum or collection. It is important that the endometrial cavity is carefully closed if it has been entered. Closure is achieved with a size 3-0 absorbable polyglycolic acid suture (Fig. 9.96). If there is any

Fig. 9.93: Open myomectomy. The peritoneal flap has been drawn downwards. In this type of case, there may be great difficulty in stripping the peritoneum from the front of the uterus. The separation is easier if the fibroid lies immediately beneath the peritoneum. The myometrium beneath the flap has been incised longitudinally and the fibroid exposed.

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Fig. 9.94: Open myomectomy. Enucleation of the tumour from the uterus. The fibroid is drawn up with traction using a Vulsellum forceps, and its attachments to the myometrium of the pseudocapsule are divided by sharp dissection with Mayo’s scissors.

Fig. 9.95: Open myomectomy. In this case, the endometrial cavity has been opened and the endometrial layer is being closed carefully with a fine absorbable suture.

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doubt as to whether the endometrial cavity has been entered, methylene blue dye can be injected vaginally into the cavity through a Spackman cannula. If the cavity has been breached, the Spackman cannula itself may be directly visible. The myometrium is often closed in two or three layers using either interrupted or continuous sutures. It is important to avoid placing sutures that might interfere with the entry of the Fallopian tube at the uterine cornu. For uterine closure, the authors prefer a continuous transverse stitch to bring together the most superficial layer of myometrium (similar to a subcuticular stitch on the skin) in order to closely approximate the uterine serosa and allow it to be closed under less tension. The uterine serosal layer is traditionally closed with a continuous

non-absorbable monofilament suture (e.g. polypropylene). This is theoretically less likely to cause adhesions to surrounding structures such as small bowel. Alternatively, absorbable monofilament sutures (e.g. polydioxanone) can also be utilised. The purpose of this layer is to closely approximate the visceral peritoneum of the uterus, which in turn will promote uterine healing and reduce the chance of adhesion formation. The haemostatic clamps or tourniquets are now removed and any secondary bleeding controlled with further haemostatic sutures. Once the surgeon is satisfied that the operation area is dry, the abdomen is closed.

Cervical Fibroids About 5% of fibroids are situated in the cervix, and these pose a particular surgical problem in turns of accessing the mass. If the cervical fibroid lies anteriorly, it can be approached by a transverse division of the uterovesical peritoneum. In these cases, it is impossible to apply Bonney’s myomectomy clamp until the myoma has been removed. The clamp should be applied as soon as this has been done. Haemostasis can then be secured and the fibroid’s cavity can be closed in the normal fashion (Fig. 9.98). In some cases, a cervical fibroid can be located centrally and uniformly expands the cervix around it, and the uterus sits on top of the expanded cervix. To approach these fibroids, the uterovesical peritoneum is divided transversely as before. It may be helpful to also divide the round ligament. To reach the fibroid, it is necessary to bisect the uterus from above to provide

Fig. 9.96: Open myomectomy. The peritoneal flap has been sutured back into position.

C B

A

Fig. 9.97: Obliteration of dead spaces. A, B and C illustrate the cavities from which fibroids have been enucleated. The central cavity represents the endometrial cavity. Various types of suture designed to obliterate dead spaces are shown.

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Fig. 9.98: Cervical myomectomy. In this case, the V-shaped depression has been displaced upwards. There is a large space between the depression and the bladder. The peritoneum is loosely attached to the uterus below the V-shaped depression, and the peritoneal flap can be separated easily.

The Uterus access to the bed of the tumour, which can now be enucleated. Following enucleation, the myomectomy clamp can be applied immediately, allowing reconstruction of the uterus without excessive blood loss (Figs. 9.99, 9.100, 9.101). Diagnostic hysteroscopy using the hydrodilatation technique may be useful

as part of an assessment of the exact location of a cervical fibroid in relation to the cervical canal, prior to performing an incision on the uterus. If the fibroid lies posteriorly in the cervix, it will have to be enucleated by a low posterior incision in the back of the uterus in the pouch of Douglas. This may be vertical or transverse depending on the exact position of the fibroid, access to the pelvis and the individual surgeon’s preference. Such an incision, of course, leaves a posterior scar, which is unavoidable.

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Broad Ligament Fibroids

Fig. 9.99: Cervical myomectomy. The surgical approach to a cervical fibroid by bisection of the uterus.

Fig. 9.100: Cervical myomectomy. Enucleation of a cervical fibroid by bisection of the uterus. A forcep has been passed down the cervical canal to identify its direction, while the cervical tumour is enucleated.

Fibroids that grow laterally into the broad ligament are relatively easy to deal with (Fig. 9.102). There is usually a clear dissection plane between the fibroid and the loose areolar tissue of the broad ligament, and closure is relatively straight-forward as there is usually plenty of peritoneum available to cover the incision. Three important points must be stressed in these cases: (1) Broad ligament fibroids can be associated with a secondary polycythaemia, which in turn can lead to impaired haemostasis72 or thrombosis. (2) Careful closure of the tumour bed is imperative to prevent haematoma formation, which may complicate the postoperative course with febrile morbidity or even sepsis. Care must also be taken to avoid the uterine artery and vein during dissection of the fibroid. (3) There is a risk of damage to the ureter, which may be displaced from its normal position and be vulnerable to surgical injury. When incising the capsule for removal of a broad ligament fibroid, the ureter should always be identified to prevent iatrogenic injury (Fig. 9.101).

Fig. 9.101: Cervical myomectomy. The bisected uterus may be reconstructed with two layers of interrupted sutures.

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Submucosal Fibroids Large submucosal fibroids are best dealt with hysteroscopically (see earlier in chapter), sometimes after a course of GnRHa injections. Particularly large submucous fibroids, unsuitable for hysteroscopic resection, may be approached by open myomectomy via an anterior uterine incision and a transcavity approach.

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“Seedling” Fibroids In some cases, the myometrium contains multiple small “seedling” fibroids, and the surgeon needs to decide intraoperatively at what point it is not worth pursuing such small lesions. In general, it is probably best to limit myomectomy to those lesions that are greater than 1 cm. Logically, where multiple lesions exist the risk of symptomatic fibroid recurrence is higher, and it may be prudent to advise planning conception earlier rather than later if appropriate for the patient. If pregnancy is not desired in the near future, medical management may be a more suitable approach, but clearly the management will need to be tailored to an individual’s symptoms and wishes.

Vaginal Myomectomy This is a less common approach to myomectomy, but has its obvious advantages in relation to postoperative recovery and return to normal activities. Vaginal myomectomy for fibroids a large as 250 g has been described via a posterior colpotomy, using a combination of morcellation and bisection following 3–4 months of GnRH analogue therapy.128 Some pedunculated submucosal fibroids can be removed after performing a

Fig. 9.102: Broad ligament myomectomy. A left broad ligament fibroid being enucleated by incision of the capsule. The location and path of the ureter must be identified before the incision is made.

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hysterotomy by a vaginal approach (see Figs. 9.8, 9.9 earlier in this chapter).

Laparoscopic Myomectomy Potential laparoscopic myomectomy cases should fulfill the necessary selection criteria to confirm feasibility of the operative approach. Pre-operative investigations should include a pelvic ultrasound to determine the size, location and number of fibroids. Any intracavitary fibroids can be identified on ultrasound scan as being amenable to hysteroscopic resection. Technical problems include haemostasis, uterine closure and tissue removal. These issues have prompted several proponents to impose limits on the number and size of fibroids amenable to laparoscopic surgery. Dubuisson, for example, suggests that the open approach should be favoured if a single fibroid measures more than 8 cm in diameter, or if there are more than two fibroids to be removed.129,130 In the 20 years since Dubuisson’s preliminary reports on laparoscopic myomectomy,131 the limits to what is achievable by the laparoscopic approach are increasingly being re-evaluated, and will invariably depend on operator experience. Fibroids of more than 15 cm in diameter, weighing in excess of 1400 g have subsequently been reported at laparoscopic myomectomy.132 In the authors’ experience, size of an individual fibroid is rarely a contraindication. The positioning for laparoscopic myomectomy is similar to laparoscopic hysterectomy with the legs abducted, hips straight and the knees flexed to 90º. An indwelling urinary catheter is sited and a bimanual examination is performed to assess the size and mobility of the uterus and the location of the fibroids. This, along with the pre-operative ultrasound findings, will help to confirm the suitability of the case for a laparoscopic approach. A diagnostic hysteroscopy should be performed at this point if it has not recently been done to assess for submucous fibroids, which might be treatable by hysteroscopic resection. A uterine manipulator is inserted through the cervical os to the upper limit of the endometrial cavity. Routine umbilical laparoscopic entry is then performed (see Chapter 3), unless the fibroid uterus extends to the level of the umbilicus or above, in which case entry at Palmer’s point may be necessary. At least two lateral 5 mm accessory ports are inserted at a level high enough to allow unobstructed passage of the lateral instruments over the fundus of the uterus. The authors use a further 5 mm midline suprapubic port to assist in dissection and enucleation of the fibroids. Following careful laparoscopic inspection of the peritoneal surfaces, the location of the fibroids is ascertained in relation to the round ligaments, ovaries and Fallopian tubes (Fig. 9.103). These serve as useful guides of the relationship of the fibroids to the endometrial cavity. It is the authors’ practice to then inject a solution of 20 iu of vasopressin diluted in 20 ml of 0.9% normal saline into the myometrium at the base of each fibroid, in order to induce vasoconstriction and reduce intra-operative blood loss. Care must be taken to avoid inadvertent intravenous administration of vasopressin, as serious cardiopulmonary side-effects have been described.132

The Uterus

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Fig. 9.103: Laparoscopic myomectomy. There is a large posterofundal subserosal fibroid. The round ligaments and Fallopian tube insertions are anterior to the mass.

Fig. 9.105: Laparoscopic myomectomy. The fibroid is grasped with a 10 mm claw forceps through the left lateral port. Normal myometrial tissue anterior to the fibroid has been dissected away.

Subserosal and Intramyometrial Fibroids The technique will depend upon the fibroid location. In the case of pedunculated subserosal fibroids, the pedicle can simply be treated with bipolar diathermy forceps close to the normal uterine myometrium, before division with laparoscopic scissors. In the case of intramyometrial or subserosal fibroids, the uterus must be incised. This can be achieved with a variety of instruments and energy sources, such as a monopolar diathermy hook or an ultrasonic scalpel. The incision is made directly over the fibroid, either transversely or obliquely in order to facilitate suturing of the defect after enucleation. The incision is made to the depth of the pseudocapsule where the plane of cleavage is identified (Fig. 9.104). The fibroid is then placed under tension with a grasping forceps or a myoma screw, to provide traction out of the uterine incision and facilitate enucleation (Figs. 9.105, 9.106). Fig. 9.106: Laparoscopic myomectomy. In this image, the fibroid has been successfully dissected out and away from the uterus.

Fig. 9.104: Laparoscopic myomectomy. A transverse/oblique incision has been made. The psudocapsule has been identified and grasped before the fibroid can be dissected out.

During the enucleation process, small vessels can be coagulated with bipolar forceps. Dissection with an energy source rather than cold scissors helps achieve haemostasis. This is important not only to reduce blood loss but to ensure a clear surgical view through the laparoscope. Commonly larger blood vessels are located near the base of the fibroid, and again these should be treated with bipolar diathermy. Once the fibroid is removed, any additional bleeding vessels in the fibroid’s cavity can be inspected and coagulated. The myometrial defect must then be closed, except in the case of very superficial, pedunculated fibroids. There are various suturing options for closure of the defect in the myometrium and serosa. A continuous or interrupted suture can be used. Deeper defects will need to be closed in layers, just as in the case of open myomectomy. The authors prefer an interrupted No. 1 187

Section B | Benign Conditions: The Cervix, Vagina and Vulva, Uterus, Ovaries and Fallopian Tubes polyglactin suture for myometrial closure, tied with extracorporeal knots (Figs. 9.107–9.109). The uterine serosa is then closed. The authors’ choice for this final layer is closure with an absorbable, unidirectional barbed suture that does not require a knot at either end; however, other suture material and methods of suturing are equally acceptable (Figs. 9.110–9.112).

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Broad Ligament Fibroids For a broad ligament fibroid, the incision is made through the avascular anterior leaf of the broad ligament. The round ligament can also be divided if further space is required for dissection. It is important to identify the uterine vessels and the ureter, after which dissection is usually relatively straightforward. The uterine defect can then be closed, along with either the anterior or posterior leaf

Fig 9.109: Laparoscopic myomectomy. The right hand side of the myometrial defect is now closed. The uterine serosa has not been sutured yet.

Fig. 9.107: Laparoscopic myomectomy. A large raw myometrial defect remains where the fibroid has been dissected out. A No. 1 polyglactin suture has been placed at the base of the defect and an extracorporeal knot is about to be tied. Fig. 9.110: Laparoscopic myomectomy. Following closure of the myometrial defect, the uterine serosa is being closed. In this image, a barbed, unidirectional, absorbable suture is being used to close the serosa. This confers the advantage of not needing to be tied for security.

of the broad ligament (to prevent small bowel herniation through the peritoneal defect) (Figs. 9.113–9.115).

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Fig 9.108: Laparoscopic myomectomy. A knot pusher is being used to tighten an extracorporeally tied knot.

Once the uterine defects have been closed and haemostasis confirmed, the fibroids must be removed from the peritoneal cavity. Small fibroids can be mechanically morcellated and removed piecemeal either through the ancillary ports or by extension of the skin incision. For larger fibroids, a minilaparotomy incision can be performed to either remove them intact or to allow access with conventional instruments for

The Uterus

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Fig. 9.111: Laparoscopic myomectomy. The uterine serosa has now been completely closed and the uterine anatomy has been restored to normal.

Fig. 9.114: Laparoscopic myomectomy. The broad ligament fibroid has been dissected out after careful identification of the right ureter and uterine vessels.

Fig. 9.112: Laparoscopic myomectomy. Alternative uterine serosal closure with interrupted No. 1 polyglactin sutures. Fig. 9.115: Laparoscopic myomectomy. An oxidised cellulose polymer has been placed in the broad ligament defect to act as a haemostatic agent.

Fig. 9.113: Laparoscopic myomectomy. A right sided broad ligament fibroid.

mechanical morcellation. However, this technique negates one of the main advantages of laparoscopic surgery, namely the rapid recovery rate, reduced analgesia requirement and shorter hospital stay afforded by small endoscopic incisions. One elegant alternative is to place the fibroids in an endoscopic bag and then perform a posterior colpotomy, either laparoscopically or vaginally, to allow removal of the specimens through the vagina. The fibroids can be morcellated in the vagina if needed to facilitate extraction. Electrical morcellators have also been developed.133 They are introduced into the pelvis through a 10–20 mm port. Tissue morcellation can still be a relatively lengthy procedure for large fibroids (Fig. 9.116). Electric tissue morcellators are potentially dangerous instruments, and they should only be used by 189

Section B | Benign Conditions: The Cervix, Vagina and Vulva, Uterus, Ovaries and Fallopian Tubes Table 9.16:

Complications of myomectomy

Haemorrhage (intraperitoneal or intramyometrial) Hysterectomy Post-myomectomy pyrexia Paralytic ileus Postoperative adhesions Small bowel obstruction

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Bladder/ureteric injury Subfertility (tubal damage or adhesions) Endometriosis/adenomyosis Fibroid recurrence Uterine rupture in pregnancy

Fig. 9.116: Laparoscopic myomectomy. The fibroid is being morcellated with an electrical morcellator. An external motor drives a circular blade, through which the fibroid is passed. Cylindrical strips of morcellated fibroid are removed through the associated port and sent for histology.

experienced laparoscopic surgeons who have received the necessary training. It is imperative that the fibroid being morcellated is kept well clear of the bowel and adjacent blood vessels such as the internal and external iliac vessels. Tissue morcellation is not appropriate if there is concern regarding possible malignancy, as it risks peritoneal or port-site tumour seeding and only allows histological assessment of piecemeal tumour rather than an entire, untouched specimen. Prior to closure, a synthetic adhesion barrier can be applied to the surgical site in the uterus. If an electrical morcellator has been used through a port of 10 mm or larger, the incised rectus sheath at the port site should be closed to prevent a postoperative hernia.

Parasitic Myomas Occasionally, pedunculated subserosal fibroids develop a new blood supply separate from the uterine myometrium (e.g. vaginal, peritoneal or mesenteric fibroids), termed parasitic myomas. There is evidence that parasitic myomas are more common after surgery using morcellation techniques, prompting awareness that these can have an iatrogenic aetiology. With the increasing popularity of laparoscopic myomectomy, surgeons must take precautions to minimise parasitic fibroid occurrence, by ensuring meticulous removal of fibroid chippings from the peritoneal cavity following morcellation.90

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Myomectomy can result in both short- and long-term complications (see Table 9.16). In addition, laparoscopic myomectomy carries the usual risks of laparoscopic surgery including trocar insertion accidents, excessive intra-operative bleeding and the need to convert to laparotomy in as much as 10% of cases.134 The use of

morcellation techniques is also thought to increase the risk of parasitic myoma formation, and electrical morcellators carry an obvious inherent risk of serious intra-abdominal trauma. Some research suggests that compared with open myomectomy, the laparoscopic approach may be associated with a higher risk of uterine rupture in subsequent pregnancy,130,135 although evidence for this is limited. Hysteroscopic myomectomy and its complications are discussed earlier in this chapter. Slight oozing from the uterine incision is inevitable, but myomectomy is notoriously associated with postoperative bleeding, which can either cause a significant myometrial haematoma or intraperitoneal haemorrhage. The use of intramyometrial vasopressin or intra-operative uterine tourniquets run the risk of re-perfusion bleeding after the operation is complete. It is wise to employ meticulous haemostasis by atraumatic suture techniques and to have a low threshold for inserting a drain in the pelvis. The abdomen should never be closed until the surgeon is satisfied with uterine haemostasis. Transfusion rates have been reported to be as high as 20% following abdominal myomectomy.136 The conversion rate from myomectomy to hysterectomy, due to massive intraoperative bleeding, has been quoted as 2%.137 Postoperative fever has been reported to occur in as many as 36% of patients.109 The cause is thought to be due to the release of fever-inducing factors during dissection of the fibroid, or possibly due to haematomas forming in the dead space left by the enucleated fibroids. A low threshold for postoperative antibiotic cover is recommended. Open myomectomy is commonly associated with gaseous distension of the bowel and in some cases with paralytic ileus. This is usually a manifestation of intraperitoneal oozing of blood. Peritonitis is fortunately a rare complication, but a pelvic haematoma can become infected and form a pelvic abscess. Adhesions have already been discussed earlier in the chapter, and are a particular risk with posterior uterine incisions. Accidental trauma to surrounding structures is of course possible. Injury to the bladder or ureter is particularly likely when dealing with cervical and broad ligament fibroids. Interstitial Fallopian tube damage, either by incision or suture, must be most carefully avoided when dealing with fibroids near the uterine cornu.

The Uterus Viable endometrium may implant in the dead space from which a fibroid has been removed. This produces an adenomyoma, a painful swelling in the uterus, and is particularly likely to occur if the uterine cavity has been opened. The incidence of postoperative fibroid recurrence was quoted in a follow-up of 379 patients by Bonney at under 4%.120 It may be that more realistic estimates are available today with the help of ultrasound and magnetic resonance imaging. More recently fibroid recurrence has been quoted to be as high as 46% at one year post-myomectomy.138 The risk of uterine rupture in subsequent pregnancy or vaginal delivery is between 0% and 1%.110 There is debate regarding how long a couple should wait to conceive following a myomectomy. A longer duration after myomectomy may allow for better uterine healing, although there is also a risk of recurrence of fibroids with time. Most surgeons advise a 3–6 month recovery interval before conceiving. There is also debate as to the best advice on mode of delivery after myomectomy, with very little evidence to rely on. Indications for Caesarean section are relative and may depend on various obstetric factors. Although normal delivery may be possible following myomectomy, rupture of the uterus is a well-recognised risk.139,140 This appears to be more likely in the presence of a vertical incision in the body of the uterus or if the cavity has been entered, signifying a full thickness myometrial wound. In these cases, it is preferable to advise elective Caesarean section. There is also an increased risk of postpartum haemorrhage and possibly abnormal placental adherence to the myomectomy scar secondary to localised placenta accreta. It is the authors’ practice to advise elective Caesarean in women who have had more than 50% of the myometrial thickness incised to remove a fibroid, in cases of multiple large fibroids with multiple uterine incisions, or as described above, in the case of a vertical upper segment uterine myomectomy scar that mimics a classical Caesarean section incision. In Bonney’s famous and unique series of 806 operations, the mortality was 1.1%.120 Of the nine fatal cases, two were from pulmonary embolism, three from intestinal obstruction, one from secondary haemorrhage, and one from necrosis of the uterine wall caused by the over-use of mattress sutures. Two patients died of haemorrhagic shock, both of whom were pregnant. It should be stressed that myomectomy in pregnancy is to be avoided at all costs, including at Caesarean section. The greatest number of tumours removed at one operation was 225; in another case 40 tumours were removed, with a combined weight of 21 lb (9.5 kg). In one case, the tumour proved to be a sarcoma.

greatest improvement was with hysterectomy.143 In any patient undergoing myomectomy, it is prudent to consider postoperative contraception in the short term. It is the authors’ preference to advise delaying conception for 3 months after surgery to allow sufficient time for maximal uterine muscular integrity. Unless other forms of contraception are contraindicated, it is sensible to avoid use of an intra-uterine device during this initial postoperative recovery. Current medical, surgical, radiological and anaesthetic practice has contributed to safe and effective treatment of fibroids with uterine conservation in almost all cases, whilst progress in endoscopic surgery has benefited patients by radically reducing postoperative pain, length of hospital stay and recovery time, reducing adhesion formation and improving their reproductive potential.

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O UTC O ME Satisfactory reduction in menstrual loss occurs in 90–95% of cases, and whilst robust prospective data is lacking, retrospective studies of subfertility patients describe pregnancy rates between 39% and 75%.2,141,142 In a comparison of leiomyoma therapies, myomectomy, hysterectomy and uterine artery embolisation all resulted in substantial symptom relief to near normal levels 12 months after treatment. Unsurprisingly, the

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104. Goldberg J, Pereira L, Berghella V. Pregnancy ater uterine artery embolization. Obstetrics and Gynecology. 2002;100(5):869–72. 105. Homer H, Saridogan E. Pregnancy outcomes ater uterine artery embolisation for ibroids. he Obstetrician & Gynaecologist. 2009;11:265–70. 106. Liu JP, Yang H, Xia Y, Cardini F. Herbal preparations for uterine ibroids (Review). Cochrane Database of Sytematic Reviews. 2010, Issue 11. 107. Atlee WL. Successful extirpation of a ibroid tumour of the peritoneal surface of the uterus by the large peritoneal section. Am J Med Science. 1845;9:309–35. 108. Sawin SW, Pilevsky ND, Berlin JA, et al. Comparability of perioperative morbidity between abdominal myomectomy and hysterectomy for women with uterine leiomyomas. Am J Obstet Gynecol. 2000;183(6):1448–55. 109. Celik H, Sapmaz E. Use of a single preoperative dose of misoprostol is eicacious for patients who undergo abdominal myomectomy. Fertil Steril. 2003;79:1207–10. 110. Kongnyuy EJ, Wiysonge CS. Interventions to reduce haemorrhage during myomectomy for ibroids (Review). Cochrane Database of Sytematic Reviews. 2010, Issue 11. 111. Taylor A, Sharma M, Tsirkas P, Di Spiezio Sardo A, Setchell M, Magos A. Reducing blood loss at open myomectomy using triple tourniquets: a randomised controlled trial. BJOG. 2005;112:340–5. 112. Lethaby A, Vollenhoven B, Sowter MC. Pre-operative GnRH analogue therapy before hysterectomy or myomectomy for uterine ibroids (Review). Cochrane Database of Sytematic Reviews. 2011, Issue 1. 113. Miskry T, Magos A. Laparoscopic myomectomy. Seminars in Laparoscopic Surgery. 1999;6(2):73–9. 114. Frederick J, Hardie M, Reid M, Fletcher H, Wynter S, Frederick C. Operative morbidity and reproductive outcomes in secondary myomectomy: a prospective cohort. Hum Reprod. 2002;17: 2967–71. 115. Practice Committee of the American Society for Reproductive Medicine: Society of Reproductive Surgeons. Pathogenesis, consequences and control of peritoneal adhesions in gynecologic surgery. Fertil Steril. 2007;88:21–6. 116. Ahmad G, Dufy JMN, Farquhar C, et al. Barrier agents for adhesion prevention ater gynaecological surgery (Review). Cochrane Database of Sytematic Reviews. 2010, Issue 11. 117. Tulandi T, Murray C, Guralnick M. Adhesion formation and reproductive outcome ater myomectomy and second-look laparoscopy. Obstet Gynecol. 1993;82:213–5. 118. Tulandi T. How can we avoid adhesions ater laparoscopic surgery? Curr Opinion Obstet Gynecol. 1997;9:239–43. 119. Griiths AN, D’Angelo A, Amso NN. Surgical treatment of ibroids for subfertility (review). Cochrane Database of Sytematic Reviews. 2010, Issue 11. 120. Bonney V. he techniques and results of myomectomy. Lancet. 1931;220:171–7. 121. Bonney V. he technical minutiae of extended myomectomy and ovarian cystectomy. Cassell: London; 1946. 122. Jin C, Hu Y, Chen X, et al. Laparoscopic versus open myomectomy—a meta-analysis of randomized controlled trials. Eur J Obstet Gyn R B. 2009;145:14–21.

123. Seracchioli R, Rossi S, Govoni F, et al. Fertility and obstetric outcome ater laparoscopic myomectomy of large myomata: a randomized comparison with abdominal delivery. Hum Reprod. 2000;15(12):2663–8. 124. Hurst BS, Matthews ML, Marshburn PB. Laparoscopic myomectomy for symptomatic uterine myomas. Fertil Steril. 2005;83(1):1– 23. 125. Barakat E, Bedaiwy M, Zimberg S, Nutter B, Nossier M, Falcone T. Robotic-assisted, laparoscopic, and abdominal myomectomy: a comparison of surgical outcomes. Obstet Gynecol. 2011;117(2):256–65. 126. Matthews CA. Applications of robotic surgery in gynecology. J Womens Health. 2010;19(5):863–7. 127. Farrer-Brown G, Beilby JOW, Tarbit MH. he vascular patterns in myomatous uteri. J Obstet Gynaecol Br Commw. 1970;77:967–70. 128. Magos AL, Bournas N, Sinha R, Richardson R, O’Connor H. Vaginal Myomectomy. BJOG. 1994;101(12):1092–4. 129. Dubuisson JB, Chapron C, Levy L. Diiculties and complications of laparoscopic myomectomy. J Gynecol Surg. 1996;12:159–65. 130. Dubuisson JB, Chapron C, Fauconnier A, Kreiker G. Laparoscopic myomectomy and myolysis. Curr Opin Obstet Gyn. 1997;9:233–8. 131. Dubuisson JB, Lecru F, Foulot H, et al. Myomectomy by laparoscopy: a preliminary report of 43 cases. Fertil Steril. 1991;56:827–30. 132. Parker RB, Chudasama A, Chudasama M. Laparoscopic myomectomy of a large pedunculated ibroid: case report. East Afr Med J. 2008;85(7):362–4. 133. Tulandi T, Beique F, Kimia M. Pulmonary edema: a complication of local injection of vasopressin at laparoscopy. Fertil Steril. 1996;66:478–80. 134. Steiner RA, Wight E, Tadir Y, Haller U. Electrical device for laparoscopic removal of tissue from the abdominal cavity. Obstet Gynecol. 1993;81:471–4. 135. Dubuisson JB, Chavet X, Chapron C, et al. Uterine rupture during pregnancy ater laparoscopic myomectomy. Hum Reprod. 1995;10:1475. 136. La Morte AI, Lalwani S, Diamond MP. Morbidity associated with abdominal myomectomy. Obstet Gynecol. 1993;82(6): 897–900. 137. Aubuchon M, Pinto AB, Williams DB. Treatment of uterine ibroids. Primary Care Update Ob/Gyns. 2002;9:231–37. 138. Nishiyama S, Saito M, Sato K, Kurishito M, Itasaka T, Shioda K. High recurrence rate of uterine ibroids on transvaginal ultrasound ater abdominal myomectomy in Japanese women. Gynecol Obstet Inves. 2006;61:155–9. 139. Schrinsky D, Benson R. Rupture of the pregnant uterus: a review. Obstet Gynecol Surv. 1978;33:217–32. 140. Landon MB, Lynch CD. Optimal timing and mode of delivery ater cesarean with previous classical incision or myomectomy: a review of the data. Semin Perinatol. 2011;35(5):257–61. 141. Darai E, Dechaud H, Benila JL, et al. Fertility ater laparoscopic myomectomy: preliminary results. Hum Reprod. 1997;12:1931–34. 142. Miller CE, Johnston M, Rundell M. Laparoscopic myomectomy in the infertile woman. J Am Assoc Gynecol Laparosc. 1996;3:525–32. 143. Spies JB, Bradley LD, Guido R, Maxwell GL, Levine BA, Coyne K. Outcomes from leiomyoma therapies: comparison with normal controls. Obstet Gynecol. 2010;116(3):641–52.

The O va rie s

10

Jane Borley, Alan Farthing

Be nig n O va ria n C ysts DEFINITIO NS AND SYMPTO MS Ovarian cysts or masses arise from a physiological or a neoplastic process. The World Health Organisation classifies ovarian tumours depending on their precursor origin (Table 10.1). This can be broadly divided into epithelial tumours, sex-cord stroma tumours and germ-cell tumours; all of which can either be benign or malignant or borderline in the case of epithelial cell. (For ovarian malignancy please refer to Chapter 17). Ovarian cysts may be asymptomatic and found incidentally clinically or by ultrasound scan. Alternatively they may cause pain or discomfort, or present with bladder or bowel disturbance if they are large and exert pressure on surrounding viscera. Ovarian cyst accidents or torsion may present acutely with severe abdominal pain, which may radiate to the thigh, and are often associated with nausea and vomiting. Functional cysts: The physiological process of ovulation can lead to the development of ovarian functional cysts but these are not pathological. Functional cysts arise from a Graafian follicle (the dominant follicle in the menstrual cycle) or a

Table 10.1: Classification of benign ovarian tumours with some examples Epithelial

Serous Mucinous

Cystadenoma, adenołbroma and cystadenołbroma

Endometrioid Clear cell Transitional cell Thecoma-łbroma

Granulosa-stromal cell Steroid cell tumours

Meigs syndrome is an eponym that describes a benign łbroma of the ovary associated with ascites and a pleural effusion May secrete androgens, oestrogens and progestogens

Sertoli-stromal cell Germ-cell

Iatrogenic cysts will be present after ovulation induction therapy and can reach a significant size in ovarian hyperstimulation syndrome (see Chapter 12). Although this condition is common in assisted fertility techniques (33% of IVF cycles causing mild disease and a further 3–8% causing moderate to severe disease4), surgical input is rare and in fact should be avoided. Surgical intervention is only required for serious complications, namely rupture and haemorrhage or torsion. Polycystic ovary syndrome (PCOS) is a complex syndrome with long-term health consequences including type 2 diabetes mellitus, sleep apnoea, increased rates of subfertility, endometrial hyperplasia and possible endometrial carcinoma.5 For diagnosis of PCOS two of the three Rotterdam criteria6 have to be present: (i) appearances of polycystic ovaries on ultrasound—either 12 or more peripheral follicles or an increased ovarian volume (>10 cm3), (ii) oligo- or amenorrhoea, (iii) clinical and/or biochemical signs of hyperandrogenism. Surgery is rarely indicated except in the case of clomiphene ovulation–induction resistance where ovarian drilling has been shown to be as effective as gonadotrophin treatment without the risk of multiple pregnancy.7

Brenner tumour

Mixed epithelial Sex cordstromal

corpus luteum. Approximately 80–90% of simple cysts are found to resolve spontaneously after 6–12 weeks.1,2 There is no recognised maximum size of a functional cyst, and they can occasionally be extremely large. There are reports of functional cysts being >30 cm in diameter,3 and if they are causing symptoms then surgical removal may be necessary. However, because of their tendency to regress the management of a simple cyst in an asymptomatic patient should be conservative with ultrasound follow-up.

Mature teratoma

Dermoid cyst

Thyroid tumour

Struma ovarii

DIAG NO SIS A large ovarian cyst should be palpable abdominally arising from the pelvis. Smaller cysts will be palpable on bimanual examination by the presence of fullness in either adnexa. Positive examination findings will be easily missed if the patient is overweight or there is patient discomfort during the examination. Pelvic ultrasound scan will detect pathology in the majority of cases. Both transabdominal and a transvaginal approach should be used whenever possible. A transvaginal approach has been shown to improve sensitivity when compared

Section B | Benign Conditions: The Cervix, Vagina and Vulva, Uterus, Ovaries and Fallopian Tubes Table 10.2: An example of RMI scores and the subsequent percentage risk of cancer9,11

10

Fig. 10.1: Left ovarian cyst.

to a transabdominal approach for smaller cysts,8 whereas transabdominal scanning will pick up very large cysts, which may be otherwise missed. Magnetic resonance imaging (MRI) of the pelvis and abdominal computed tomography (CT) may be used if there is concern of malignancy or originating site of the pathology. (See Chapter 4). Diagnostic laparoscopy may be useful for further evaluation of a suspected cyst on occasion, and laparoscopy for pelvic pain or infertility may result in the finding of a previously unsuspected ovarian cyst (see Fig. 10.1).

MANAG EMENT The most important question on assessment of ovarian cysts is whether there are features suspicious of malignancy. It is recommended that a risk of malignancy index be calculated to select women who are at high risk of having a malignant tumour and thus be referred and managed by the appropriate team.9 Low-risk women can be operated upon by a general gynaecologist, moderate risk at a cancer unit and high risk at a cancer centre (Table 10.2). If an ovarian tumour is removed and subsequently found to be malignant, it may be necessary to subject the patient to a further abdominal operation for correct treatment and staging. This includes removal of the contralateral ovary, hysterectomy and omentectomy. Risk of malignancy can be calculated by the patient’s age, ultrasound findings and CA125 level. RMI ⴝ U ⴛ M ⴛ CA125 U = ultrasound score with 1 point being given for each suspicious features on ultrasound, e.g. a multi-loculated cyst, evidence of solid areas or papillary projections, bilateral disease, presence of ascites or metastasis. U = 0 (for ultrasound score of 0); U = 1 (for ultrasound score of 1); U = 3 (for ultrasound score of 2–5). M = 1 for pre-menopausal, M = 3 for post-menopausal women. CA125 is serum CA125 measurement in u/mL.

196

Risk of malignancy

RMI score

Low

40 Total ____________________ Endometriosis

1–3 cm

>3 cm

Superłcial Deep

1 2

2 4

4 6

R Superłcial Deep

1 4

2 16

4 20

L Superłcial Deep

1 4

2 16

4 20

Posterior cul de sac obliteration

Partial

Complete

4

40

2/3 Enclosure

1

2

4

4

8

16

1

2

4

Ovary

R Filmy Dense L Filmy Dense R Filmy Tube

DYSMENO RRHO EA

100 mL/min) or medium (50–100 mL/min). First sensation (150–200 mL) and maximum cystometric capacity (400– 600 mL) are noted during the filling phase and the bladder is generally filled to a maximum of 500 mL. During the filling phase, the bladder pressure is constantly recorded. In the normal physiological state, the bladder is a low-pressure compliant storage organ. Low compliance is the term used to indicate a gradual steep rise in pressure during bladder filling and is generally regarded as being ⱖ15 cm H2O at a capacity of 500 mL. Detrusor overactivity is characterised by involuntary bladder contractions that occur during the filling phase (Fig. 13.2). These may be spontaneous or provoked and cannot be suppressed. Provocation may include rapid filling, tap running, hand washing and coughing. At the end of filling the urethral catheter is removed and the patient stands up. A series of coughs are then performed testing for urodynamic stress incontinence. In those women having VCU, simultaneous X-ray screening is performed to assess the anatomy of the bladder neck and also to screen for leakage.

Voiding Cystometry The final stage of urodynamics is to ask the women to void on the flowmeter with both the abdominal and vesical pressure lines in situ, thus producing a pressure flow study. Women normally void with a detrusor pressure of 15 mL/s for a voided volume of at least 150 mL.10 A low flow rate in conjunction with a relatively high voiding pressure and urinary residual may be indicative of voiding difficulties. In addition, in some women with longterm voiding difficulties the detrusor muscle may decompensate and lead to a picture of low pressure and low flow.

13

Urethral Pressure Prołlometry Urethral pressure profilometry (UPP) is a graphical recording of pressure within the urethra at successive points along its length. A catheter mounted solid-state pressure transducer with the two transducers 6 cm apart is passed into the bladder. As the catheter is withdrawn, the pressure differential between the two transducers is recorded giving the maximum urethral closure pressure (MUCP) and functional urethral length (FUL) (Fig. 13.3). Whilst not diagnostic of urodynamic stress incontinence a very low maximum urethral closure pressure has been shown to be associated with a poor outcome following continence surgery.11 It may also be useful in those women with voiding difficulties in order to exclude a urethral stricture.

Fig. 13.2: Cystometrogram showing severe systolic and provoked detrusor contractions during łlling.

243

26

1:20

26

26

1:10

1:00 UPP Stop 2 UPP Start 3

26

1:00 UPP Stop 2 UPP Start 3 24

50

22

25

UPP Start 2 40

UPP Stop 1

25 100

UPP Stop 1

UPP Start 2

20 20

20

64

20

20

15

15

67

⫺5

⫺5

Graph Title: Pull 3

⫺5

⫺5

40

⫺5 ⫺7

⫺50

Graph Title: Pull 2

⫺7

43

⫺50

Patient Name: 24/06/03 Test Name: Urethral Pressure Profile Graph Title: Pull 1 Pclo (cm H2O)

⫺4

100 ⫺5

⫺5 100 ⫺5

Pura (cm H2O)

20

100 ⫺5

20 100 ⫺5

Pves (cm H2O)

13

22

24

24

100

30

20

10 UPP Start 1

Section C | Urogynaecology and the Pelvic Floor

Fig. 13.3: Urethral pressure prołlometry in a patient with a urethral diverticulum.

C o nse rva tive The ra p y fo r Stre ss Urina ry Inc o ntine nc e Whilst some women will ultimately require surgery for stress urinary incontinence, many will benefit initially from a conservative approach using a combination of pelvic floor muscle training with, or without, concomitant medical therapy.

PELVIC FLO O R MUSC LE TRA INING Pelvic floor muscle training (PFMT) and pelvic floor physiotherapy remain the first-line conservative measure since their introduction in 1948.12 PFMT appears to work in a number of different ways: Women learn to consciously pre-contract the pelvic floor muscles before and during increases in abdominal pressure to prevent leakage (‘the knack’). Strength training builds up long-lasting muscle volume and thus provides structural support. 244

Abdominal muscle training indirectly strengthens the pelvic floor muscles.13 In addition during a contraction the urethra may also be pressed against the posterior aspect of the symphysis pubis producing a mechanical rise in urethral pressure.14 Since up to 30% of women with stress incontinence are unable to contract their pelvic floor correctly at presentation,15 some patients may simply need to be re-taught the ‘knack’ of squeezing the appropriate muscles at the correct time.16 Cure rates varying between 21% and 84% have been reported.17,18 Success appears to depend upon the type and severity of incontinence treated, the instruction and follow-up given, the compliance of the patient and the outcome measures used. However, the evidence would suggest that PFMT is more effective if patients are given a structured programme to follow rather than simple verbal instructions.19 The success of PFMT may be further enhanced by the use of biofeedback.20 This technique allows patients to receive visual or audio feedback relating to contraction of their pelvic floor. The most commonly used device in clinical practice is the

Stress Urinary Incontinence perineometer, which may give women an improved idea of a pelvic floor contraction and provide an effective stimulus to encourage greater and continued effort.

MEDIC A L THERA PY Whilst various agents such as α1-adrenoceptor agonists, oestrogens and tricyclic anti-depressants have all been used anecdotally in the past for the treatment of stress incontinence, duloxetine is the first drug to be specifically developed and licensed for this indication. Duloxetine is a potent and balanced serotonin (5-hydroxytryptamine) and noradrenaline re-uptake inhibitor (SNRI), which enhances urethral-striated sphincter activity via a centrally mediated pathway.21 The efficacy and safety of duloxetine (20 mg, 40 mg, 80 mg) has been evaluated in a double-blind randomised parallel group placebo-controlled phase II dose finding study in 48 centres in the United States involving 553 women with stress incontinence.22 Duloxetine was associated with significant and dose-dependent decreases in incontinence episode frequency. Reductions were 41% for placebo and 54%, 59% and 64% for the 20, 40 and 80 mg groups, respectively. Discontinuation rates were also dose dependent—5% for placebo and 9%, 12% and 15% of 20 mg, 40 mg and 80 mg, respectively; the most frequently reported adverse event being nausea. A further global phase III study of 458 women has also been reported.23 There was a significant decrease in incontinence episode frequency and improvement in quality of life in those women taking duloxetine 40 mg once daily when compared to placebo. Once again nausea was the most frequently reported adverse event occurring in 25.1% of women receiving duloxetine compared to a rate of 3.9% in those taking placebo. However, 60% of nausea resolved by 7 days and 86% by 1 month. These findings are supported by a further double-blind, placebocontrolled study of 109 women awaiting surgery for stress incontinence.24 Overall there was a significant improvement in incontinence episode frequency and quality of life in those women taking duloxetine when compared to placebo. Furthermore, 20% of women who were awaiting continence surgery changed their mind whilst taking duloxetine. More recently, the role of synergistic therapy with pelvic floor muscle training and duloxetine has been examined in a prospective study of 201 women with stress incontinence. Women were randomised to one of four treatment combinations; duloxetine 40 mg b.d., PFMT, combination therapy or placebo. Overall duloxetine, with or without PFMT was found to be superior to placebo or PFMT alone whilst pad test results and quality of life analysis favoured combination therapy to single treatment.25

Surg e ry fo r Stre ss Urina ry Inc o ntine nc e A NTERIO R C O LPO RRHA PHY Anterior colporrhaphy is now rarely performed for the treatment of stress urinary incontinence and due to relatively

13

Fig. 13.4: Marshall–Marchetti–Krantz procedure.

low short-term success rates can no longer be recommended. Although it is usually the best operation for a cystourethrocoele, the cure rates for urodynamic stress incontinence are poor compared to suprapubic26 and mid-urethral tape procedures.

MA RSHA LL–MA RC HETTI–KRA NTZ PRO C EDURE The Marshall–Marchetti–Krantz27 procedure is a suprapubic operation in which the para-urethral tissue at the level of the bladder neck is sutured to the periostium and/or perichondrium of the posterior aspect of the pubic symphysis (Fig. 13.4). This procedure elevates the bladder neck but will not correct any concomitant cystocoele. It has been largely superceded by the Burch colposuspension because its complications include osteitis pubis in 2–7% of cases.

BLA DDER NEC K SUSPENSIO N PRO C EDURES Endoscopically guided bladder neck suspensions28–30 are simple to perform but are less effective than open suprapubic procedures and are now seldom used. In all these operations a long needle is used to insert a loop of nylon on each side of the bladder neck; this is tied over the rectus sheath to elevate the urethrovesical junction (Fig. 13.5). Cystoscopy is employed to ensure accurate placement of the sutures and to detect any damage to the bladder caused by the needle or the suture. In the Stamey procedure, buffers are used to avoid the sutures cutting through the tissues and in the Raz procedure, a helical suture of Prolene is inserted deep into the endopelvic fascia lateral to the bladder neck to avoid cutting through. The main problem with all these operations is that they rely on two sutures and these may break or pull through the tissues. However, endoscopically guided bladder neck suspensions are quick and easy to perform. They can be carried out under regional blockade and postoperative recovery is fast. Temporary voiding difficulties are common after long needle suspensions but these usually resolve and there are few other complications.

245

Section C | Urogynaecology and the Pelvic Floor Buffer anterior to rectus sheath

Rectus sheath

Suture between buffers

Symphysis pubis

Bladder

13 Buffer

Uterus Vagina

Rectum

Fig. 13.5: Retropubic needle suspension.

C O LPO SUSPENSIO N The Burch colposuspension has been modified by many authors, since its original description.31 Until relatively recently colposuspension has been the operation of choice in primary urodynamic stress incontinence as it corrects both stress incontinence and a cystocoele. However, it may not be suitable if the vagina is scarred or narrowed by previous surgery. Whilst the colposuspension is now well recognised as an effective procedure for stress incontinence, it is not without complications. Detrusor overactivity may occur de novo or may be unmasked by the procedure,32 which may lead to long-term urinary symptoms. Voiding difficulties are common postoperatively; although these usually resolve within a short time after the operation, long-term voiding dysfunction may result. In addition, a rectoenterocoele may be exacerbated by repositioning the vagina.33 However, the colposuspension is the only incontinence operation for which long-term data are available. Alcalay et al.34 have reported a series of 109 women with an overall cure rate of 69% at a mean of 13.8 years.

incised taking care not to open the peritoneal cavity unless a concomitant intra-abdominal procedure is being performed. A Turner–Warwick self-retaining retractor may then be inserted and the retropubic space (Cave of Retzius) is opened using both sharp and blunt dissection until the white paravaginal tissue lateral to the bladder neck and urethra is identified. Vaginal manipulation is also used to further assist in the elevation of the lateral vaginal fornices whilst the bladder is swept medially (Fig. 13.6a). Two to four delayed absorbable sutures are inserted into the para-vaginal fascia on each side and each tied down onto the vaginal tissue ensuring haemostasis. The first suture is at the level of the bladder neck and 1 cm lateral. The suture is then passed vertically through the ipsilateral iliopectineal ligament, taking care not to pull the bladder neck open and left untied. Each subsequent suture is then placed 1 cm lateral and 1 cm cephalad and all left untied before the sutures are placed on the opposite side (Fig. 13.6b). Once all the sutures are positioned correctly, each lateral fornix is elevated by an assistant allowing the sutures to be tied easily without tension. After checking for adequate haemostasis, the retropubic space is drained with a redivac suction drain and the abdomen closed. The bladder is left on free drainage

(a)

Technique The patient is positioned on the operating table in the modified lithotomy position using Lloyd-Davies stirrups. The abdomen and vagina are then prepared as a sterile operating field in order to allow manipulation of the vaginal fornices and bladder neck by the surgeon. An indwelling Foley catheter is then inserted and the balloon inflated with 6 mL of water to allow identification of the bladder neck. A low transverse suprapubic incision approximately 1 cm above the pubic symphysis is made and the rectus fascia 246

(b) Fig. 13.6a,b: Colposuspension.

Stress Urinary Incontinence using a suprapubic catheter for 48 hours prior to starting a clamping regimen. When the urinary residuals are less than 100 mL, the suprapubic catheter may be removed.

LA PA RO SC O PIC C O LPO SUSPENSIO N Minimally invasive surgery is attractive, and this trend has extended to surgery for stress incontinence and the development of laparoscopic colposuspension. Although many authors have reported excellent short-term subjective results from laparoscopic colposuspension,35 early studies have shown inferior results to the open procedure.36,37 More recently, two large prospective randomised controlled trials have been reported from Australia and the United Kingdom comparing laparoscopic and open colposuspension. In the Australian study, 200 women with urodynamic stress incontinence were randomised to either laparoscopic or open colposuspension.38 Overall, there were no significant differences in objective and subjective measures of cure or in patient satisfaction at 6 months, 24 months or 3–5 years. Whilst the laparoscopic approach took longer (87 vs. 42 min; p < 0.0001), it was associated with less blood loss (p = 0.03) and a quicker return to normal activities (p = 0.01). These findings are supported by the UK multicentre randomised controlled trial of 291 women with urodynamic stress incontinence comparing laparoscopic to open colposuspension.39 At 24 months intention to treat analysis showed no significant difference in cure rates between the procedures. Objective cure rates for open and laparoscopic colposuspension were 70.1% and 79.7%, respectively, whilst subjective cure rates were 54.6% and 54.9%, respectively. These studies have confirmed that the clinical effectiveness of the two operations is comparable although the cost effectiveness of laparoscopic colposuspension remains unproven. A cost analysis comparing laparoscopic to open colposuspension was also performed alongside the UK study.40 Healthcare resources use over the first 6-month follow-up period translated into costs of £1805 for the laparoscopic group versus £1433 for the open group.

PUBO VA G INA L SLING Sling procedures are often performed as secondary operations where there is scarring and narrowing of the vagina. The sling material can either be organic (rectus fascia, porcine dermis) or inorganic (Prolene, Mersilene, Marlex, or Silastic). The sling may be inserted either abdominally, vaginally or by a combination of both. Normally the sling is used to elevate and support the bladder neck and proximal urethra, but not intentionally to obstruct it. Sling procedures may be associated with a high incidence of side effects and complications. It is often difficult to decide how tight to make the sling. If it is too loose, incontinence will persist and if it is too tight, voiding difficulties may be permanent. Women who are going to undergo inser-

tion of a sling must be prepared to perform clean intermittent self-catheterisation postoperatively. In addition, there is a risk of infection, especially if inorganic material is used. The sling may erode into the urethra, bladder or vagina, in which case it must be removed and this can be exceedingly difficult.

Technique The procedure is performed in the dorsal lithotomy position and utilises an abdominal and vaginal approach. A transverse suprapubic incision is first made just above the pubic symphysis and the rectus fascia identified. Two parallel horizontal incisions 2 cm apart are then made in the fascia and a 16 cm sling of rectus fascia is mobilised. Each end of the strip of fascia is then secured with a non-absorbable suture and the ends left long. Following insertion of an indwelling Foley catheter, a curvilinear vaginal incision is made in the anterior vaginal wall just below the level of the bladder neck. Next, a tunnel is created superficial to the pubocervical fascia using a combination of both sharp and blunt dissection in a plane towards the patient’s ipsilateral shoulder until the endopelvic fascia is perforated. A long curved clamp may then be carefully passed downwards from the abdominal incision using the vaginal finger as a guide and also to protect the bladder and urethra. The long sutures attached to the end of the harvested fascial sling may then be pulled through the abdominal incision on each side allowing placement of the sling under the bladder neck. Two small incisions are then made in the rectus fascia and the suture ends are pulled through prior to tying them over the rectus fascia without tension. The rectus fascia may then be closed using a delayed absorbable suture prior to closing the abdominal and vaginal incisions (Fig. 13.7). At the end of the procedure a suprapubic catheter is left in situ and the bladder left on free drainage for 48 hours before a clamping regimen is instituted. The advent of the newer mid-urethral tape procedures has largely replaced the use of traditional sling procedures and whilst efficacy rates are comparable complications tend to be fewer with the newer synthetic slings. A prospective, randomised study comparing tension free vaginal tape, a pelvicol sub-urethral sling and a traditional autologous fascial sling has been reported.41 Overall 201 women were randomised in four centres over 6 years and an interim analysis was performed after 50 patients were completed in each arm. Due to high failure and re-intervention rates, the pelvicol arm was closed after this analysis. At 1-year followup cure and improvement rates were no different between the TVT arm and the fascial sling arm (55% vs. 45%) and (93% and 90%), respectively. In the pelvicol arm, cure rates were 22% and improvement 61%. The re-intervention rate was 20% in the pelvicol arm compared to 0% in the other two arms. Consequently, the evidence from this study would suggest that the newer mid-urethral retropubic tapes are as efficacious as a traditional sling.

13

247

Section C | Urogynaecology and the Pelvic Floor

13

(a)

(b)

(c)

(d)

Fig. 13.7: Rectus fascial sling. (a) Harvesting of rectus sheath. A non-absorbable suture is placed at each end of the graft and the ends left long. (b) A tunnel is created behind the pubic bone either side of the urethra allowing passage of the fascial sling. (c) A long curved clamp is guided through the endopelvic fascia to grasp the sutures on the harvested fascial sling. (d) Following placement of the fascial sling at the bladder neck, the abdominal and vaginal incisions are closed and an indwelling catheter left in place.

Mid - Ure thra l Ta p e Pro c e d ure s RETRO PUBIC MID- URETHRA L TA PES

Tension-Free Vaginal Tape The tension-free vaginal tape (TVT, Gynaecare), first described by Ulmsten in 1996,42 is now the most commonly performed procedure for stress urinary incontinence in the UK, and more than two million procedures have been performed worldwide. A knitted 11 mm × 40 cm polypropylene mesh tape is inserted transvaginally at the level of the mid-urethra, using two 5 mm trochars (Fig. 13.8a). The procedure may be performed under local, spinal or general anaesthesia. Most women can go home the same day, although some do require catheterisation for short-term voiding difficulties (2.5–19.7%). Other complications 248

include bladder perforation (2.7–5.8%), de novo urgency (0.2– 15%) and bleeding (0.9–2.3%).43 The initial multicentre study carried out in six centres in Sweden reported a 90% cure rate at 1 year in women undergoing their first operation for urodynamic stress incontinence, without any major complications.44 Long-term results would confirm durability of the technique with success rates of 86% at 3 years,45 84.7% at 5 years,46 81.3% at 7 years47 and 90% at 11 years.48 The tension-free vaginal tape has also been compared to open colposuspension in a multicentre prospective randomised trial of 344 women with urodynamic stress incontinence.49 Overall there was no significant difference in terms of objective cure; 66% in the tension-free vaginal tape group and 57% in the colposuspension group. However, operation time, postoperative stay and return to normal activity were all longer in the colposuspension

Stress Urinary Incontinence arm. Analysis of the long-term results at 24 months using a pad test, quality of life assessment and symptom questionnaires showed an objective cure rate of 63% in the tension-free vaginal tape arm and 51% in the colposuspension arm.50 At 5 years, there were no differences in subjective cure (63% in the tension-free vaginal tape group and 70% in the colposuspension group), patient satisfaction and quality of life assessment. However, whilst there was a significant reduction in cystocoele in both groups there was a higher incidence of enterocoele, rectocoele and apical prolapse in the colposuspension group.51 Furthermore, cost utility analysis has also shown that at 6-months follow-up tension-free vaginal tape resulted in a mean cost saving of £243 when compared to colposuspension.52 A smaller randomised study has also compared tensionfree vaginal tape to laparoscopic colposuspension in 72

women with urodynamic stress incontinence. At a mean follow-up of 20 months objective cure rates were higher in the tension-free vaginal tape group when compared to the laparoscopic colposuspension group; 96.8% vs. 71.2% respectively (p = 0.056).53

Technique The TVT device consists of an 11 mm wide by 40 cm long tape of polypropylene mesh, both ends of which are attached to a stainless steel curved 5 mm diameter needle. The tape is covered by a protective plastic sheath and a reusable stainless steel handle is used to insert the needles. The procedure may be performed under local or general anaesthesia. The patient is placed in the dorsal lithotomy position

(a)

(c)

(b)

(d)

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Fig. 13.8a–d: Tension-free vaginal tape (TVT).

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and having prepared the vagina and suprapubic area an indwelling 18Fr Foley catheter is inserted into the bladder. Once the bladder has been emptied a rigid catheter guide is then inserted down the catheter in order to deflect the bladder away from the passage of the needle introducers. The use of local anaesthesia (20 mL bupivacaine 0.5% with 1 in 200,000 adrenaline – diluted in 100 mL normal saline) allows effective hydrodissection and vasoconstriction whilst at the same time providing effective intra-operative and postoperative analgesia. Twenty millilitres of dilute local anaesthetic is injected on each side retropubically immediately behind the pubic tubercle. In addition, further 20 mL is injected para-urethrally on each side up to the level of the urogenital diaphragm and 5 mL sub-urethrally. A 2-cm-midline sub-urethral vaginal incision is made and para-urethral dissection performed using sharp dissection with McIndoe scissors between the vaginal mucosa and pubocervical fascia to the level of the inferior pubic ramus and the urogenital diaphragm (Fig. 13.8b). Two small 0.5 cm suprapubic incisions at the upper border of the pubic tubercle 2 cm lateral to the midline may be made to facilitate needle passage through the skin. The TVT needle is then placed in the starting position within the dissected para-urethral tunnel with the tip of the needle between the index finger (in the vagina) and the lower border of the pubic ramus. Prior to the passage of the needle the bladder is pushed away from the track of the needle using the rigid catheter guide. In a controlled movement the needle is then pushed through the urogenital diaphragm, the retropubic space and the rectus fascia keeping in close contact to the dorsal aspect of the pubic bone. The procedure is then repeated on the contralateral side (Fig. 13.8c). With the needles still in position a cystoscopy using a 70o cystoscope is performed to check that there is no bladder injury (Fig. 13.8d). Should a bladder perforation be noted the needle is withdrawn, replaced, passed once again and the cystoscopy repeated. Once the integrity of the bladder is confirmed the bladder is again emptied completely and the tape pulled through. In the centres that continue to use the cough stress test, the bladder is then refilled with 300 mL normal saline and the patient asked to cough vigorously. The tape may then be adjusted to a point where there is only a drop of leakage from the urethral meatus. After this final adjustment the tape is held in position beneath the urethra using a pair of McIndoe scissors whilst the plastic sheaths are removed on each side. In the centres where a cough stress test is no longer used the tape is positioned loosely below the mid-urethra without tension. Finally, the vaginal incision is closed using an absorbable suture and the suprapubic incisions are closed with Steristrips. Whilst an indwelling catheter is not required in all cases a urethral catheter should be left on free drainage for 48 hours following a bladder injury.

SPA RC — MID- URETHRA L SLING SUSPENSIO N SYSTEM The SPARC sling system (American Medical Systems) is a minimally invasive sling procedure using a knitted 10-mm250

wide polypropylene mesh, which is placed at the level of the mid-urethra by passing the needle via a suprapubic to vaginal approach.54 The procedure may be performed under local, regional or general anaesthetic. A prospective multicentre study of 104 women with urodynamic stress incontinence has been reported from France.55 At a mean follow-up of 11.9 months the objective cure rate was 90.4% and subjective cure 72%. There was a 10.5% incidence of bladder perforation and 11.5% of women complained of de novo urgency following the procedure. More recently SPARC has been compared to tension-free vaginal tape in a prospective randomised trial of 301 women.56 At short-term follow-up, there were no significant differences in cure rates, bladder perforation rates and de novo urgency. There was, however, a higher incidence of voiding difficulties and vaginal erosions in the SPARC group.

Technique The procedure may be performed under local or general anaesthesia. The patient is placed in the dorsal lithotomy position and having prepared the vagina and suprapubic area an indwelling 18Fr Foley catheter is inserted into the bladder. The use of local anaesthesia (20 mL bupivacaine 0.5% with 1 in 200,000 adrenaline – diluted in 100 mL normal saline) allows effective hydrodissection and vasoconstriction whilst at the same time providing effective intra-operative and postoperative analgesia. Twenty millilitres of dilute local anaesthetic is injected on each side retropubically immediately behind the pubic tubercle. Two 0.5 cm incisions are made directly above the level of the pubic tubercle on each side 1.5 cm from the midline. After identification of the bladder neck, a 2 cm midline sub-urethral incision is then made prior to para-urethral sharp dissection between the vaginal epithelium and peri-urethral fascia using McIndoe scissors. Dissection is continued to the inferior border of the pubic ramus at the level of the mid-urethra. The insertion needles are passed from above to below. The needle is first passed through the suprapubic incision down to the pubic tubercle before being rotated around the superior aspect of the bone to perforate the rectus fascia and muscle. The needle is then passed over the posterior aspect of the pubic bone to reach the endopelvic fascia before being guided through the vaginal incision using a finger placed in the vagina or incision itself. The procedure is then repeated on the opposite side. Following passage of both needles, cystoscopy—using a 70o cystoscope—is performed to exclude a urethral or bladder injury. Should a perforation be noted, the bladder is emptied, needles re-positioned and a repeat cystoscopy performed. Next, the connectors on each end of the tape are attached to the needles in the vaginal incision and the tape is gently pulled through on each side taking care to make sure that the tape remains flat under the mid-urethra. If there is any suspicion of bladder injury then a repeat cystoscopy should be performed. The tape is then held loosely in position beneath the urethra

Stress Urinary Incontinence using a pair of McIndoe scissors, whilst the protective plastic sheaths are removed ensuring that there is no tension on the urethra. The vaginal incision may then be closed using an absorbable suture and Steri-strips are used to close the two small suprapubic incisions. Whilst an indwelling catheter is not required in all cases, a urethral catheter should be left on free drainage for 48 hours following a bladder injury (Fig. 13.9).

Angle handle cranially

45°

TRA NSO BTURA TO R SLING PRO C EDURES The transobturator route for the placement of synthetic mid-urethral slings was first described in 2001.57 As with the retropubic sling procedures, transobturator tapes may be performed under local, regional or general anaesthetic and have the theoretical advantage of eliminating some of the complications associated with the retropubic route, such as bladder and urethral perforation. However, the transobturator route may be associated with damage to the obturator nerve and vessels; in an anatomical dissection model, the tape passes 3.4 cm and 4.8 cm from the anterior and posterior branches of the obturator nerve, respectively, and 1.1 cm from the most medial branch of the obturator vessels.58 Consequently, nerve and vessel injury in addition to bladder injury and vaginal erosion remain a potential complication of the procedure. The transobturator approach may be used as an ‘inside-out’ (TVT-O, Gynaecare) (Fig. 13.10a) or alternatively an ‘outside–in’ (Monarc, American Medical Systems) technique. To date there have been several studies documenting the short-term efficacy of transobturator procedures. Initial studies have reported cure and improved rates of 80.5% and 7.5%, respectively at 7 months59 and 90.6% and 9.4%, respectively at 17 months.60 More recently the transobturator approach (TVT-O) has been compared to the retropubic approach (TVT) in an Italian prospective multicentre randomised study of 231 women with urodynamic stress incontinence.61 At a mean of 9 months subjectively, 92% of women in the TVT group were cured compared to 87% in the TVT-O group. Objectively, on pad test testing, cure rates were 92% and 89%, respectively. There were no differences in voiding difficulties and length of stay, although there were more bladder perforations in the TVT group—4% vs. none in the TVT-O group. A further multicentre prospective randomised trial comparing TVT and TVT-O has also recently been reported from Finland in 267 women complaining of stress urinary incontinence.62 Objective cure rates at 9 weeks were 98.5% in the TVT group and 95.4% in the TVT-O group (p = 0.1362). Whilst complication rates were low and similar in both arms of the study, there was a higher incidence of groin pain in the TVT-O group (21 vs. 2; p = 0.0001). This data is supported by a recent meta-analysis of the five randomised trials comparing TVTO with TVT and six randomised trials comparing TOT with TVT.63 Overall subjective cure rates were identical with the retropubic and transobturator routes. However, adverse events such as bladder injuries (OR 0.12; 95% CI: 0.05–0.33) and voiding difficulties (OR 0.55; 95% CI: 0.31–0.98) were less common, whereas groin pain (OR 8.28; 95% CI: 2.7–25.4) and vaginal erosions (OR 1.96; 95% CI: 0.87–4.39) were more common after the transobturator approach.

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(a)

(b)

(c) Fig.13.9: SPARC sling system. (a) Placement of the needle tip and perforation of the endopelvic fascia. (b) Once the needles have been passed, the tape may then be connected prior to being pulled through and positioned correctly. (c) The tape is carefully positioned under the mid-urethra without tension.

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Long-term data would also seem to support the durability and efficacy of the transobturator approach. A 3-year follow-up study of a prospective, observational study evaluating the use of TVT-O has recently been reported.64 Of the 102 patients recruited, 91 (89.2%) were available for follow-up at a minimum of 3 years. The objective cure rate was 88.4% with an improvement in 9.3% of cases and there was no statistical difference in outcome as compared to the results reported at 1 year. In addition there was also a significant improvement in subjective outcome including incontinence severity and quality of life. Whilst four patients required tape division there were no cases of erosion or persistent pain.

The tape is then held loosely in position beneath the urethra using a pair of McIndoe scissors whilst the protective plastic sheaths are removed ensuring that there is no tension on the

Technique Transobturator ‘Inside-Out’ The TVT-O device consists of an 11 mm wide by 40 cm long tape of polypropylene mesh both ends of which are attached to a plastic sheath that threads over the helical needle introducer. A winged needle guide is also provided to facilitate passage of the needle through the obturator membrane. The procedure may be performed under local or general anaesthesia. The patient is placed in the dorsal lithotomy position in 120o hyperflexion. The vagina and thighs are then prepared and an indwelling 12Fr Foley catheter is inserted into the bladder. Next two 0.5 cm incisions are made 2 cm superior to a horizontal line level with the urethra and 2 cm lateral to the thigh folds. This marks the exit point for the helical needle introducer. The use of local anaesthesia (20 mL bupivacaine 0.5% with 1 in 200,000 adrenaline – diluted in 100 mL normal saline) allows effective hydrodissection and vasoconstriction whilst at the same time providing effective intra-operative and postoperative analgesia. Twenty millilitres of dilute local anaesthetic is injected paraurethrally on each side in the direction of the inferior pubic ramus. A midline sub-urethral incision is then made at the level of the mid-urethra prior to para-urethral sharp dissection between the vaginal epithelium and peri-urethral fascia using McIndoe scissors. Dissection is continued laterally to the inferior border of the pubic ramus at the level of the midurethra and the medial aspect of the obturator membrane is perforated. The winged needle guide is then passed at 45o relative to the sagittal plane of the urethra until reaching the posterior aspect of the inferior pubic ramus and perforating the obturator membrane. Having mounted the tape onto the helical introducer the tip is then placed along the guide channel in the winged guide to pass through the obturator membrane and is then rotated so as to exit trough the inner thigh incision. The tip of the tubing is then clamped and the helical introducer withdrawn. The procedure is then repeated on the contralateral side (Fig. 13.10b). Once both needles have been passed and the tape inserted a cystoscopy may be performed to exclude bladder or urethral injury. 252

(a)

(b)

(c) Fig. 13.10a–c: TVT-O Transobturator System (inside-out).

Stress Urinary Incontinence urethra and the tape is lying flat (Fig. 13.10c). The vaginal incision is then closed using an absorbable suture and Steri-strips are used to close the two small incisions on the thighs. Whilst an indwelling catheter is not required in all cases a urethral catheter should be left on free drainage for 48 hours following a bladder injury.

Transobturator ‘Outside-In’ The procedure may be performed under local or general anaesthesia. The patient is placed in the dorsal lithotomy position in 120o hyperflexion. The vagina and thighs are then prepared and an indwelling 12Fr Foley catheter is inserted into the bladder. The use of local anaesthesia (20 mL bupivacaine 0.5% with 1 in 200,000 adrenaline – diluted in 100 mL normal saline) allows effective hydrodissection and vasoconstriction, whilst at the same time providing effective intra-operative and postoperative analgesia. Twenty millilitres of dilute local anaesthetic is injected paraurethrally on each side in the direction of the inferior pubic ramus. A midline sub-urethral incision is then made at the level of the mid-urethra prior to para-urethral sharp dissection between the vaginal epithelium and peri-urethral fascia using McIndoe scissors. Dissection is continued laterally to the inferior border of the pubic ramus at the level of the mid-urethra and the medial aspect of the obturator membrane is perforated. Next, a small incision is made 1.5 cm lateral to the ischiopubic ramus on each side at the level of the clitoris. The helical needle introducer is then passed ‘outside – in’ through the incision to perforate the medial aspect of the obturator membrane. With the index finger in the vaginal incision palpating the ischiopubic ramus and obturator internus muscle the tip of the helical needle may then be guided through to the vaginal incision. Care should be taken to avoid perforating the lateral vaginal fornix and the urethra is guarded by the operator’s finger. Once the tip of the needle has been passed through the vaginal incision the tape may then be attached to the needle and pulled through to exit through the thigh incision. The procedure is then repeated on the contralateral side. The tape is then held loosely in position beneath the urethra using a pair of McIndoe scissors, whilst the protective plastic sheaths are removed ensuring that there is no tension on the urethra and the tape is lying flat. The vaginal incision is then closed using an absorbable suture and Steri-strips are used to close the two small incisions on the thighs. Whilst an indwelling catheter is not required in all cases, a urethral catheter should be left on free drainage for 48 hours following a bladder injury.

MINIMA LLY INVA SIVE TA PE PRO C EDURES Whilst the development of the mid-urethral retropubic and transobturator tapes has transformed the surgical approach to stress urinary incontinence by offering a minimally invasive day case procedure, there has recently been interest in developing a new type of ‘mini sling’ that may offer a truly office-based approach. The TVT-Secur is the first of these mini

slings to be introduced although there are several other devices currently under investigation and development.

G YNEC A RE TVT- SEC UR The TVT-Secur was launched in 2006 and currently there is little long-term data supporting its use although several shortterm studies have been reported. The first published case series reported on a small sample of 15 women with an overall subjective cure rate of 93% at 1–3 month follow-up.65 More recently a multicentre prospective trial has been reported from Italy in 95 women with primary stress incontinence who had a TVT-Secur. Follow-up at 1 year reported a subjective and objective cure rates of 78% and 81%, respectively whilst 8% of women complained of voiding difficulties. In addition there were two cases of mesh erosion.66 This data is supported by a multicentre prospective observational study in France of 150 patients with 1 year follow-up. Cure and improvement rates were 76.9% in those women with pure stress incontinence although this fell to 60% in a smaller group with intrinsic sphincter deficiency.67 The current evidence would appear to suggest that TVT-Secur efficacy rates may be slightly inferior to those of the retropubic mid-urethral tapes68 and current experience would suggest that the procedure is technically different from a retropubic or obturator approach. Initial success rates have been disappointing in some series and the effect of the ‘learning curve’ has been clearly documented with objective success rates increasing from 76.2% to 94.7% depending on the experience of the operating surgeon.69 From the available clinical evidence available to date it would appear that TVT-Secur offers an alternative, minimally invasive approach for the treatment of stress urinary incontinence although more data are required to document the longterm efficacy and safety.

13

Technique The TVT-Secur device consists of an 11 mm wide by 8-cm-long tape of polypropylene mesh both ends of which are sandwiched between a fleece pad composed of a woven polyglactin and polyp-dioxane fibres (Fig. 13.11a). The pads are locked in position on the end of two stainless steel inserters allowing accurate retropubic placement. Following the release of the locking mechanism the pads may then be released at the time of insertion. The procedure may be performed under local or general anaesthesia. The patient is placed in the dorsal lithotomy position and having prepared the vagina and suprapubic area an indwelling 18Fr Foley catheter is inserted into the bladder. Once the bladder has been emptied a rigid catheter guide is then inserted down the catheter in order to deflect the bladder away from the passage of the needle introducers. The use of local anaesthesia (20 mL bupivacaine 0.5% with 1 in 200,000 adrenaline – diluted in 100 mL normal saline) allows effective hydrodissection and vasoconstriction whilst at the same time providing effective intra-operative and postoperative analgesia. Twenty millilitres are injected para-urethrally on each side up to the level of the urogenital diaphragm and 5 mL suburethrally. 253

Section C | Urogynaecology and the Pelvic Floor A 1.5 cm midline sub-urethral vaginal incision is made and para-urethral dissection performed using sharp dissection with McIndoe scissors between the vaginal mucosa and pubocervical fascia to a depth of 1 cm. If the placement is retropubic (‘U’ position) the angle of dissection is 45o whilst if an obturator (Hammock) placement is planned dissection is at 90° or horizontally.

U Position Once the protective cover has been removed from the tip the introducer is then held using a needle holder making sure the inserter is inline with the handle of the instrument. The tip of the introducer is then carefully placed within the paraurethrally dissected tunnel using the index finger on the finger pad. The

13

(a)

(b)

(c) Fig. 13.11: (a) TVT-Secur. (b) TVT Secur: ‘U’ placement. (c) TVT Secur: ‘Hammock’ placement.

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Stress Urinary Incontinence inserter should then be pushed at 45o towards the ipsilateral shoulder using gentle pressure. When contact is made with the posterior surface of the pubic bone the pad is held carefully in place against the bone whilst the needle holder is released leaving the inserter in position. The procedure is then repeated on the contralateral side. (Fig. 13.11b)

Hammock Position Once the protective cover has been removed from the tip the introducer is then held using a needle holder making sure the inserter is inline with the handle of the instrument. The tip of the introducer is then carefully placed within the para-urethrally dissected tunnel using the index finger on the finger pad. The inserter tip should then be orientated at 45o from the midline towards the ischiopubic ramus whilst holding the needle holder parallel to the floor. Once contact is made with the posterior surface of the pubic bone the pad is held carefully in place against the bone whilst the needle holder is released leaving the inserter in position. The procedure is then repeated on the contralateral side (Fig. 13.11c). After both inserters have been passed final tape positioning may be performed by adjusting the depth of insertion on each side. Care should be taken to ensure that the inserter tip remains in contact with the posterior surface of the pubic bone on each side and that the tape is flat and lies immediately beneath the urethra. Prior to removal of the inserters cystourethroscopy should be performed to exclude injury to the bladder or urethra. Should a bladder perforation be noted, the inserter should be removed and replaced. Once the tape is properly positioned, the first inserter is released by gently pulling on the release wire and then sliding the inserter out from the incision. Care should be taken not to dislodge the anchoring pad from the posterior surface of the pubic bone. The procedure should then be completed on the opposite side. The vaginal incision is then closed using an absorbable suture. Whilst an indwelling catheter is not required in all cases, a urethral catheter should be left on free drainage for 48 hours following a bladder injury.

Table 13.2:

Urethral bulking agents

Urethral bulking agent

Application technique

Glutaraldehyde cross-linked bovine collagen (Contigen)

Cystoscopic

Polydimethylsiloxane (Macroplastique)

Cystoscopic MIS Implantation System

Pyrolytic carbon coated zirconium oxide beads in ␤ Glucan gel (Durasphere)

Cystoscopic

Calcium hydroxylapatite in carboxymethylcellulose gel (Coaptite)

Cystoscopic

Polyacrylamide hydrogel (Bulkamid)

Cystoscopic

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Ure thra l Bulking A g e nts Urethral bulking agents are a minimally invasive surgical procedure for the treatment of urodynamic stress incontinence and may be useful in the elderly and those women who have undergone previous operations and have a fixed, scarred fibrosed urethra. Although the actual substance that is injected may differ the principle is the same. It is injected either peri-urethrally or transurethrally on either side of the bladder neck under cystoscopic control and is intended to ‘bulk’ the bladder neck, in order to stop premature bladder neck opening, without causing out-flow obstruction. They may be performed under local, regional or general anaesthesia. There are now several different products available. (Table 13.2) The use of minimally invasive implantation systems (Fig. 13.12) has also allowed some of

Fig. 13.12: Macroplastique urethral bulking agent and implantation device.

these procedures to be performed in the office setting without the need for cystoscopy. In the first reported series 81% of 68 women were dry following two injections with collagen.70 There have been long-term followup studies most of which give a less than 50% objective cure rate at 2 years but a subjective improvement rate of about 70%.71,72

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Macroplastique has more recently been compared to Contigen in a North American study of 248 women with urodynamic stress incontinence. Outcome was assessed objectively using pad tests and subjectively at 12 months. Overall objective cure and improvement rates favoured Macroplastique over Contigen (74% vs. 65%; p = 0.13). Whilst this difference was not significant subjective cure rates were higher in the Macroplastique group (41% vs. 29%; p = 0.07).73 Whilst success rates with urethral bulking agents are generally lower than those with conventional continence surgery they are minimally invasive and have lower complication rates meaning that they remain a useful alternative in selected women and in those with multiple comorbidities.

A rtiÀc ia l Urina ry Sp hinc te r An artificial urinary sphincter is a mechanical device that may be employed when conventional surgery fails.74 This is implantable and consists of a fluid-filled inflatable cuff, which is surgically placed around the bladder neck. A reservoir, containing fluid, is sited in the peritoneal cavity and a small finger-operated pump is situated in the left labium majus. The three major components are connected via a control valve. Under normal circumstances the cuff is inflated, thus obstructing the urethra. When voiding is desired the pump is utilised to empty the fluid in the cuff back into the balloon reservoir so that voiding may occur. The cuff then gradually refills over the next few minutes. Whilst they may be useful in women with recurrent stress incontinence artificial sphincters may be associated with many problems. In addition they are expensive, the surgery required to insert them is complicated and the tissues around the bladder neck following previous failed operations may be unsuitable for the implantation of the cuff. In addition, mechanical failure may occur, necessitating further surgery. However, there remains a place for these devices and their technology continues to evolve and improve. Unfortunately, there are a few unfortunate women in whom neither conventional nor even the newer forms of incontinence surgery produce an effective cure. For them a urinary diversion may be a more satisfactory long-term solution than the continued use of incontinence aids.

and transobturator tapes, continence surgery has moved from being an inpatient procedure to the day surgery setting and may now be performed under local or regional anaesthesia. Consequently, the number of continence procedures has increased dramatically and the move towards the development of the ‘mini tapes’ may mean that surgical options for stress urinary incontinence become an office-based procedure. An increased choice of surgical procedures and techniques should ultimately benefit both patients and clinicians. However, despite the rapid pace of innovations in the field of continence surgery it remains paramount that new procedures should be evidence based and only be introduced following adequate clinical studies demonstrating both efficacy and safety.

Re fe re nc e s 1.

2.

3.

4.

5. 6.

7.

8.

9.

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C o nc lusio n

10.

Urinary stress incontinence is the most commonly reported type of urinary incontinence in women and is known to have a significant impact on Quality of Life.75 Whilst the majority of women will benefit from a conservative approach initially surgery remains integral in the management of women with moderate to severe symptoms. The last decade has seen a dramatic change in our approach to continence surgery and, following the description of the integral theory, the focus has shifted from the bladder neck to the level of the mid-urethra. With the development of both the retropubic

11. 12.

13.

14.

Haylen BT, de Ridder D, Freeman RM, et al. An International Urogynaecological Association (IUGA)/International Continence Society (ICS) joint report on the terminology for female pelvic loor dysfunction. Int Urogynecol J. 2010;21:5–26. Hannestad YS, Rortveit G, Sandvik H, Hunskar S. A communitybased epidemiological survey of female urinary incontinence: he Norwegian EPINCONT Study. J Clin Epidem. 2000;53:1150–7. Rortveit G, Hannnestad YS, Daltveit AK, Hunskaar S. Age and type dependent efects of parity on urinary incontinence: the Norwegian EPINCONT study. Obstet Gynaecol. 2001;98:1004–10. Petros P, Ulmsten U. An integral theory of female urinary incontinence. Experimental and clinical considerations. Acta Obstet Gynaecol Scand. 1990;153(Suppl):7–31. Ingelman-Sundberg A. Urinary incontinence in women, excluding istulas. Acta Obstet Gynaecol Scand. 1953;31:266–95. Westbury M, Asmussen M, Ulmsten U. Location of maximal intraurethral pressure related to urogenital diaphragm in the female subject as studied by simultaneous urethra-cystometry and voiding urethrocystography. Am J Obstet Gynaecol. 1982;144:408– 12. Cardozo L, Stanton SL. Detrusor instability following surgery for genuine stress incontinence: a review of 200 cases. Br J Obstet Gynaecol. 1980;7:184–90. Jarvis GJ, Hall S, Stamp S, et al. An assessment of urodynamic investigation in incontinent women. Br J Obstet Gynaecol. 1980;87:893–6. Cutner A. Urolowmetry. In: Cardozo L, ed. Urogynaecology. London: Churchill Livingstone; 1997, 109–16. Benness C. Cystometry. In: Cardozo L, ed. Urogynaecology. London: Churchill Livingstone; 1997, 117–33. Monga A, Stanton SL. Predicting outcome of colposuspension-a prospective evaluation. Neurourol Urodyn. 1997;16:354–5. Kegel AH. Progressive resistance exercise in the functional restoration of the perineal muscles. Am J Obstet Gynaecol. 1948;56:238– 49. Bo K. Pelvic loor muscle training is efective in treatment of female stress urinary incontinence, but how does it work? Int Urogynaecol J Pelvic Floor Dysfunct. 2004;15:76–84. DeLancey JOL. Anatomy and mechanics of structures around the vesical neck: how vesical position may afect its closure. Neurourol Urodyn. 1988;7:161–2.

Stress Urinary Incontinence 15. Bo K, Larsen S, Oseid S, Kvarstein B, Hagen RH. Knowledge about and ability to correct pelvic loor muscle exercises in women with urinary stress incontinence. Neurourol Urodyn. 1988;7:261–2. 16. Miller JM, Ashton Miller JA, DeLancey JOL. A pelvic muscle precontraction can reduce cough-related urine loss in selected women with mild SUI. J Am Geriatric Soc. 1998;46:870–1. 17. Bo K, Talseth T, Holme I. Single blind, randomised controlled trial of pelvic loor muscles exercises, electrical stimulation, vaginal cones and no treatment in management of genuine stress incontinence in women. Br Med J. 1999;318:487–93. 18. Bernstein IT. he pelvic loor muscles: muscle thickness in healthy and urinary incontinent women measured by perineal ultrasonography with reference to the efect of pelvic loor training. Oestrogen receptor studies. Neurourol Urodyn. 1997;16: 237–75. 19. Bo K, Hagen RH, Kvarstein B, Jorgensen J, Larsen S. Pelvic loor muscle exercise for the treatment of female stress urinary incontinence. III: Efects of two diferent degrees of pelvic loor muscle exercise. Neurourol Urodyn. 1990;9:489–502. 20. Burgio KL, Robinson JC, Engel BT. he role of biofeedback in Kegel exercise training for stress urinary incontinence. Am J Obstet Gynaecol. 1986;154:58–63. 21. hor KB, Katoiasc MA. Efects of Duloxetine, a combined serotonin and norepinephrine reuptake inhibitor, on central neural control of lower urinary tract function in the chloraloseanesthetised female cat. Pharmacol Exp her. 1995;74:1014–24. 22. Norton PA, Zinner NR, Yalcin I, Bump RC, Duloxetine Urinary Incontinence Study Group. Duloxetine versus placebo in the treatment of stress urinary incontinence. Am J Obstet Gynaecol. 2002;187(1):40–8. 23. Millard R, Moore K, Yalcin I, Bump R. Duloxetine vs. placebo in the treatment of stress urinary incontinence: a global phase III study. Neurourol Urodynam. 2003;22:482–3. 24. Cardozo L, Drutz HP, Baygani SK, Bump RC. Pharmacological treatment of women awaiting surgery for stress urinary incontinence. Obstet Gynaecol. 2004;104:511–9. 25. Ghoniem GM, Van Leeuwen JS, Elser DM, Freeman RM, Zhao YD, Yalcin I, Bump RC & Duloxetine/Pelvic Floor Muscle Training Clinical Trial Group. A randomised controlled trial of duloxetine alone, pelvic loor muscle training alone, combined treatment and no active treatment in women with stress urinary incontinence. J Urol. 2005;173:1453. 26. Hilton P. Which operation for which patient? In: Drife J, Hilton P & Stanton SL, eds. Micturition. Berlin: Springer-Verlag; 1990. 27. Marshall VF, Marchetti AA, Krantz KE. he correction of stress incontinence by simple vesicourethral suspension. Surg Gynaecol Obstet. 1949;88:509–18. 28. Pereyra A. A simpliied surgical procedure for the correction of stress incontinence in women. West J Surg. 1959;67:223. 29. Stamey T. Endoscopic suspension of the vesical neck for urinary incontinence. Surg Gynecol Obstet. 1973;136:547–54. 30. Raz S. Modiied bladder neck suspension for female stress incontinence. Urology. 1981;17:82. 31. Burch J. Urethrovaginal ixation to Cooper’s ligament for correction of stress incontinence, cystocele and prolapse. Am J Obstet Gynaecol. 1961;81:281. 32. Cardozo LD, Stanton SL, Williams JE. Detrusor instability following surgery for stress incontinence. Br J Urol. 1979;58:138–42. 33. Wiskind AK, Creighton SM, Stanton SL. he incidence of genital prolapse following the Burch colposuspension operation. Neurourol Urodyn. 1991;10:453–4.

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Alcalay M, Monga A, Stanton SL. Burch colposuspension: 10-20 year follow-up. Br J Obstet Gynaecol. 1995;102:740–5. Liu CY. Laparoscopic retropubic colposuspension (Burch procedure): a review of 58 cases. J Reprod Med. 1993;38:526–30. Burton G. A randomised comparison of laparoscopic and open colposuspension. Neurourol Urodyn. 1994;13:497–8. Su T, Wang K, Hsu C, Wei H, Hong B. Prospective comparison of laparoscopic and traditional colposuspension in the treatment of genuine stress incontinence. Acta Obstet Gynecol Scand. 1997;76:576–82. Carey MP, Goh JT, Rosamilia A, et al. Laparoscopic versus open Burch colposuspension: a randomised controlled trial. BJOG. 2006;113:999–1006. Kitchener HC, Dunn G, Lawton V, Reid F, Nelson L, Smith ARB on behalf of the COLPO study group. Laparoscopic versus open colposuspension- results of a prospective randomised controlled trial. BJOG. 2006;113:1007–13. Dumville JC, Manca A, Kitchener HC, Smith ARB, Nelson L, Torgerson DJ, on behalf of the COLPO study group. Cost efectiveness analysis of open colposuspension versus laparoscopic colposuspension in the treatment of urodynamic stress incontinence. BJOG. 2006;113:1014–22. Guerrero K, Whareham K, Watkins A, Ismail S, Lucas M, Emery S. A randomised controlled trial comparing TVT, Pelvicol and autologous fascial slings for the management of stress urinary incontinence in women. Neurourol Urodynam. 2008;27:571. Ulmsten U, Henriksson L, Johnson P, Varhos G. An ambulatory surgical procedure under local anesthetic for treatment of female urinary incontinence. Int Urogynaecol J. 1996;7:81–6. Nilsson CG. Tension free vaginal tape procedure for treatment of female urinary stress incontinence. In: Cardozo L, Staskin D, eds. Textbook of Female Urology and Urogynaecology. Infoma Healthcare. Abingdon, UK; 2006, 917–23. Ulmsten U, Falconer C, Johnson P, Jones M, et al. A multicentre study of Tension Free Vaginal Tape (TVT) for surgical treatment of stress urinary incontinence. Int Urogynecol J. 1998;9:210–3. Ulmsten U, Johnson P, Rezapour M. A three year follow up of tension free vaginal tape for surgical treatment of female stress urinary incontinence. BJOG. 1999;106:345–50. Nilsson CG, Kuuva N, Falconer C, et al. Long term results of the tension free vaginal tape (TVT) procedure for surgical treatment of female stress urinary incontinence. Int Urogynaecol J. 2001;12 (suppl):5–8. Nilsson CG, Falconer C, Rezapour M. Seven year follow up of the tension free vaginal tape procedure for the treatment of urinary incontinence. Obstet Gynaecol. 2004;104:1259–62. Nilsson CG, Palva K, Rezapour M, Falconer C. Eleven years prospective follow up of the tension free vaginal tape procedure for the treatment of stress urinary incontinence. Int Urogynaecol J Pelvic Floor Dysfunct. 2008;19:1043–7. Ward K, Hilton P, United Kingdom and Ireland Tension Free Vaginal Tape Trial Group. Prospective multicentre randomised trial of tension free vaginal tape and colposuspension as primary treatment for stress incontinence. BMJ. 2002;325:67. Ward KL, Hilton P; UK and Ireland TVT Trial Group. A prospective multicentre randomised trial of tension free vaginal tape and colposuspension for primary urodynamic stress incontinence: two-year follow up. Am J Obstet Gynaecol. 2004;190:324–31. Ward K, Hilton P; UK and Ireland TVT Trial Group. Tensionfree vaginal tape versus colposuspension for primary urodynamic stress incontinence: 5 year follow up. BJOG. 2008;115:226–33.

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Manca A, Sculpher MJ, Ward K, Hilton P. A cost utility analysis of tension free vaginal tape versus colposuspension for primary urodynamic stress incontinence. BJOG. 2003;110:255–62. Paraiso MF, Walters MD, Karram MM, Barber MD. Laparoscopic Burch colposuspension versus tension free vaginal tape: a randomised trial. Obstet Gynaecol. 2004;104:1249–58. Staskin DR, Tyagi R. he SPARC sling system. Atlas Urol Clinic. 2004;12:185–95. Deval B, Levardon M, Samain E, et al. A French multicentre clinical trial of SPARC for stress urinary incontinence. Eur Urol. 2003;44:254–8. Lord HE, Taylor JD, Finn JC, et al. A randomised controlled equivalence trial of short term complications and eicacy of tension free vaginal tape and suprapubic urethral support sling for treating stress incontinence. BJU Int. 2006;98:367–76. Delorme E. Transobturator urethral suspension: mini-invasive procedure in the treatment of stress urinary incontinence in women. Prog Urol. 2001;11:1306–13. Whiteside JL, Walters MD. Anatomy of the obturator region: relations to a transobturator sling. Int Urogynaecol J Pelvic Floor Dysfunct. 2004;15:223–6. Costa P, Grise P, Droupy S, et al. Surgical treatment of female stress urinary incontinence with a transobturator tape (TOT). Uratape: short term results of a prospective multicentric study. Eur Urol. 2004;46:102–6. Delorme E, Droupy S, De Tayrac R, et al. Transobturator tape (Uratape): a new minimally invasive procedure to treat female urinary incontinence. Eur Urol. 2004;45:203–7. Meschia M, Pifarotti P, Bernasconi F, et al. Multicentre randomised trial of tension free vaginal tape (TVT) and transobturator tape in out technique (TVT-O) for the treatment of stress urinary incontinence. Int Urogynaecol J Pelvic Floor Dysfunct. 2006;17:S92–3. Laurikainen EH, Valpas A, Kiiholma P, et al. A prospective randomised trial comparing TVT and TVT-O procedures for treatment of SUI: Immediate outcome and complications. Int Urogynaecol J Pelvic Floor Dysfunct. 2006;17:S104–5. Latthe PM, Foon R, Toozs-Hobson P. Transobturator and retropubic tape procedures in stress urinary incontinence: a systematic review and meta-analysis of efectiveness and complications. BJOG. 2007;114:522–31.

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Waltregny D, Gaspar Y, Reul O, Hamida W, Bonnet P, de Leval J. TVT-O for the treatment of female stress urinary incontinence: results of a prospective study ater a 3 year minimum follow up. Eur Urol. 2008;53:401–8. Martan A, Masata J, Svabik K. TVT-Secur system – tension free support of the urethra in women sufering from stress urinary incontinence – technique and initial experience. Ceska Gynaecol. 2007;72:42–9. Meschia M, Barbacini P, Ambroqi V, Pifarotti P, Ricci L, Spreaico L. TVT-Secur: a minimally invasive procedure for the treatment of primary stress urinary incontinence. One year data from a multicentre prospective trial. Int Urogynecol J Pelvic Floor Dysfunct. 2008. Epub. Debodinance P, Lagrange E, Amblard J, Yahi H, Lucot J, Cosson M, Villet R, Jacquetin B. TVT-Secur: Prospective study and follow up to 1 year about 150 patients. Urogynaecol J Pelvic Floor Dysfunct. 2008;19:S11–2. Molden SM, Lucente VR. New minimally invasive slings: TVTSecur. Curr Urol Rep. 2008;9:358–61. Vervest H, van Dessel N, Lammerink E, Hinoul P, Roovers J. TVT-Secur: he learning curve. Urogynecol J Pelvic Floor Dysfunct. 2008;19:S3–S4. Appell RA. New Developments: injectables for urethral incompetence in women. Int Urogynaecol. 1990;1:117–9. Khullar V, Cardozo LD, et al. GAX collagen in the treatment of urinary incontinence in elderly women; a two year follow up. Br J Obstet Gynaecol. 1997;104:96–9. Stanton SL, Monga A. Incontinence in elderly women; is periurethral collagen an advance? Br J Obstet Gynaec. 1997;104: 154–7. Ghoniem G, Bernhard P, Corcos J, et al. Multicentre randomised controlled trial to evaluate Macroplastique urethral bulking agent for the treatment of female stress urinary incontinence. Int Urogynaecol J. 2005;16(2):S129–130. Scott FB, Bradley WE, Tim G. Treatment of urinary incontinence by implantable prosthetic sphincter. Urology. 1973;1:252. Kelleher CJ, Cardozo LD, Khullar V, Salvatore S. A new questionnaire to assess the quality of life of urinary incontinent women. Br J Obstet Gynaecol. 1997;104:1374–9.

Pe lvic O rg a n Pro la pse

14

Clive Spence-Jones

Intro duc tio n Pelvic organ prolapse (POP) is defined as the descent of one or more of the anterior vaginal wall, posterior vaginal wall, the uterus (cervix) or the apex of the vagina (vaginal vault after hysterectomy). The symptoms are described as a departure from normal sensation, structure or function experienced by the woman in reference to the position of her pelvic organs.1 Definitions of degrees of prolapse should include evaluation of symptoms but do not do so at the moment.2 Up to 11% of women before the age 80 undergo surgery for uterovaginal prolapse.3 The annual aggregated rate of associated surgery is 10–30/10,000 women.4 The incidence of prolapse in developing countries is hard to evaluate—a recent review suggested a mean prevalence of 19.7%, but the range was enormous 3.4–56%.5 The rate of surgery for prolapse in the USA is stable in women >52 years old but has fallen by 60% in women 8 cm). The cause of this is not known, but studies have shown that oestrogen and progesterone receptor levels are increased.30

1980 Grading system (Beecham) Midplane of vagina

Introitus

Hymenal ring

At rest Straining

Grade 3

Marked or 3rd degree

1996 Quantative POP (ICS, AUGS, SGS) Stage I

1st degree (-)1cm (+)1cm

Moderate or 2nd degree

14

EXAMINATIO N

1972 Vaginal profile (Baden) Grade 1

Slight or 1st degree

interpersonal difficulties.22 Evaluation using validated questionnaires improves our understanding of the effect of treatments. The Female Sexual Function Index23 and the Pelvic Organ Prolapse/Urinary Incontinence Sexual Questionnaire are most widely used. Studies have shown improvement after pelvic floor repair and incontinence surgery.24 Posterior vaginal repair in particular, however, may be associated with de novo dyspareunia. One study of 81 women showed a 17% incidence.25

Stage II

2nd degree

Stage III

3rd degree

Stage IV

Complete eversion Grade 4

Fig. 14.3: Grading systems of pelvic organ prolapse.

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C

recent prospective study of quality of life showed similar improvement with surgery or pessary use.31

Ba

Pessaries That can be Removed by the Patient

14 Aa

Bp Ap tvI

pb

gh

Fig.14.4: The pelvic organ prolapse quantiłcation (POPQ) uses 6 points: Aa, Ba, C, D, Ap and Bp.

The Pelvic organ prolapse staging (POPQ) was used in conjunction with six point assessment. (See Fig. 14.4).

262

A ring pessary (covered or open) is useful for the management of apical and anterior wall prolapse, if there is sufficient support from the posterior vaginal wall/perineum. A notched version of the pessary is available, which enables the patient to remove and replace the pessary herself. Intercourse is possible with a ring in place. If urinary incontinence is worse after siting a ring pessary, it will sometimes lessen if a slightly smaller pessary is used. There is a range of ring pessaries available designed to help with stress incontinence—they have an additional knob added to apply more pressure at the level of the bladder neck. The cube pessary, ‘space occupying pessary’, is available with or without perforations, and is very helpful for supporting vault/uterine prolapse, and can be removed and replaced by the patient. The cube without perforations has to be removed daily. The perforated cube can be left in situ for up to a week. Intercourse is not possible with the cube in place.

Pessaries Not Normally Removable by the Patient

Stage 0 No prolapse demonstrated Stage 1 Most distal portion of the prolapse is more than 1 cm above the level of the hymen Stage 2 Most distal portion of the prolapse is 1 cm or less proximal to or distal to the hymen Stage 3 Most distal portion of the prolapse is more than 1 cm below the plane of the hymen Stage 4 Complete eversion of the total length of the lower genital tract

The Shelf pessary/Gellhorn pessary is useful for support of the vaginal vault, but the patient is not normally able to remove the pessary herself, and intercourse is not possible. The Gehrung pessary helps for cystocoele and/or high rectocoele. Intercourse is possible but the patient cannot remove it herself. (See Fig. 14.5).

C o nse rva tive Tre a tm e nt Conservative treatment includes lifestyle changes, altering diet to help constipation (which predisposes to prolapse), reduction in caffeine and avoidance of activities that increase the degree of prolapse. Oestrogen deficiency with atrophic changes in the vagina, with or without increased bacterial presence, will increase the symptoms of soreness and awareness of prolapse. This can be corrected with topical (gel, pessary or estring) or systemic oestrogen replacement. Similarly, urinary tract infection should be identified and treated.

The ideal operation for pelvic organ prolapse would consistently give symptomatic relief, normal bladder function, bowel function and intercourse, be long lasting and not be associated with the development of new unwanted symptoms. Unfortunately no procedure has such perfect results. All surgery is therefore a compromise between the expectations of clinicians and the expectations of the patient and her family. Techniques for surgery involve vaginal or abdominal operations, with and without incorporating mesh, which may be permanent or non-permanent. As more operations are carried out and women live longer, recurrent prolapse is increasing.

SUPPO RTIVE PESSARIES

ANTERIO R C O MPARTMENT PRO LAPSE

With an improved range of pessaries available, including a range that is designed to be removed, washed and replaced by the patient; it is almost always sensible to try fitting a pessary. It is not acceptable to dismiss the use of pessaries as a treatment reserved for women too old or too ill to consider surgery— indeed it is very often older patients who present with very large prolapse and poor function of the pelvic floor, for whom it is very difficult to find a pessary to fit. It is not easy to find a pessary that is helpful for symptoms from a low rectocoele. A

Surgical correction of cystocoele remains one of the most challenging problems for pelvic floor surgeons. Laxity of the anterior vaginal wall is normal in women who have had children. Anterior vaginal repair is not an operation for stress incontinence but paradoxically around 10%32 of patients who undergo cystocoele repair who did not complain of stress incontinence pre-operatively, will develop this postoperatively. Finally, although there is up to 30% incidence of recurrent cystocoele, there is a lack of correlation between symptoms and descent.15

O b je c tive s o f Surg e ry

Pelvic Organ Prolapse

14

(a)

(b)

(c)

(d)

(e)

(f)

Fig. 14.5: Illustration of (a) ring, (b) Gehrung, (c) shelf, (d) cube, (e) doughnut and (f) Gellhorn pessaries.

The mechanism by which symptomatic anterior wall prolapse forms is poorly understood. Central defects of the pubocervical fascia cause central cystocoele with loss of vaginal rugae. Paravaginal defects caused by separation of the lateral attachments of vaginal muscularis layer to the arcus tendineus, may be bilateral or unilateral, and result in cystocoele with preservation of rugae. Standard clinical examination is a poor predictor of where the fascial defects occur, compared with intra-operative findings. Recent studies using dynamic MRI raise the possibility that the para-vaginal defect may be secondary to loss of anterior vaginal support and that loss of apical support of the anterior vaginal wall may have greater importance as a primary event. Additionally, if the perineal body is disrupted, this allows the lower anterior vaginal wall to descend through the introitus thus increasing the size of the cystocoele.33 The choice of operation for anterior vaginal prolapse includes vaginal or abdominal, with or without mesh and alone or in combination with other procedures for continence/prolapse in

other compartments. It is rare for cystocoele repair to be carried out alone.

ANTERIO R C O LPO RRHAPHY A midline incision is made from approximately 3 cm below the external urethral meatus to 2 cm from the cervix. No vaginal skin is removed at the time of initial incision, as it is not possible to assess the amount of skin to be removed, until the fascial repair has been done. The depth of the incision ensures that the muscularis fascia remains on the underlying detrusor— if the correct layer is reached the separation may be almost completely bloodless. (See Fig. 14.6). The skin edges are grasped with small Kocher forceps and the tissue plane is developed using a knife initially and then sharp dissection with fine scissors. The dissection is greatly aided by counter traction of the underlying bladder away from the vaginal skin. Many surgeons use blunt dissection using a

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14

Fig. 14.6: Cystocoele repair. Initial midline incision.

gauze swab wrapped over a finger, but this can allow dissection to go too deep into large blood vessels which are in the adventitial layer. The dissection is continued until just below the inferior border of the pubic ramus, but sometimes it is necessary to extend the dissection further laterally. (See Fig. 14.7).

264

Fig. 14.7: Cystocoele repair. The bladder, with attached pubocervical fascia, is dissected from the vaginal skin initially with sharp dissection using a knife and subsequently with scissors.

It is important to leave the fascia attached to the detrusor, not attached to the vagina. If the cystocoele is large and has been dependent for a while, the vaginal wall is very thick and bleeding occurs even when dissection is in the correct plane. An alternative approach is to leave the pubocervical fascia attached to the vaginal skin. This is achieved by dissecting deep to the fascia, separating the bladder from it, and hence leaving the fascia attached to the skin. After completion of this dissection, the repair sutures are placed into the fascia on the inner aspect of the skin on both sides. The author does not use this technique because of the risks of bladder injury, and of reducing vaginal capacity. The next step is to mobilise the bladder from the cervix. The cervix is pulled down with a vulsellum forceps. The bladder is lifted with Russian dissecting forceps and the vesicocervical ligament is divided with scissors. On each side, the bladder pillar is also divided. The peritoneum of the uterovesical pouch is exposed. The lateral extensions of the bladder are separated from the lateral border of the uterus and the front of the broad ligament. (See Fig. 14.8). Once the bladder has been mobilised from the cervix, it ensures that the ureters are excluded from the risk of inclusion in the subsequent suturing of the fascia. In most cases, the margin of the defect in the fascia cannot be readily identified, but interrupted Lembert sutures produce a musculofascial buttress to support the bladder. It is helpful to take a double bite of fascia on each side, to spread the load on each suture. Furthermore, if there is sufficient mobility, a second layer of

Fig. 14.8: Cystocoele repair. The bladder is mobilised from the underlying cervix using sharp dissection with scissors and diathermy.

Pelvic Organ Prolapse sutures pass through the white line, through the lateral edge of the pubocervical fascia and through the underside of the vaginal skin. The sutures are tied and after trimming excess vaginal skin the vagina is closed in the same way as anterior colporrhaphy. (See Figs. 14.10, 14.11).

14 Iliococcygeus muscle Detached edge of pubocervical fascia

Fig. 14.9: Cystocoele repair. The repair of cystocoele including a second layer of sutures through pubocervical fascia. Sometimes, it is necessary to include a third layer but this is not illustrated.

sutures helps to ‘laminate’ the repair. Finally, a row of interrupted sutures are placed laterally, in the pelvic diaphragm on the pelvic side of the inferior border of the inferior pubic ramus. These sutures are tied without tension in a sling-like way. (See Fig. 14.9). To reduce the risk of stress incontinence appearing for the first time following surgery, especially if there is laxity of the pubourethral supports, careful sub-urethral support is necessary.34 After redundant vaginal skin has been excised, the vaginal wall is closed with interrupted or continuous 2/0 vicryl suture. Injuries to the bladder are rare, but if the bladder has been damaged the wound can be repaired immediately using a two layer technique with absorbable sutures. One of the advantages of not emptying the bladder before this type of surgery is that an inadvertent injury is immediately apparent.

Obturator internus muscle

Arcus tendinous fascia pelvis (white line) Ischial spine

Fig. 14.10: Vaginal paravaginal repair. Untied sutures are shown passing through the white line.

PARAVAG INAL REPAIR The objective of paravaginal repair is to reattach the pubocervical fascia to the fascia over the obturator internus at the level of the arcus tendineus on both sides of the pelvis. The operation can be carried out vaginally or retropubically via an open incision or laparoscopically.

VAG INAL PARAVAG INAL REPAIR First described by White in 1909,35 the technique is recognised as technically demanding. The anterior vaginal wall is opened in the midline and if needed, a midline fascial defect is closed as with an anterior colporrhaphy. The dissection is extended laterally beneath the inferior pubic ramus, to expose the fascia over obturator internus at the level of the white line, as far as the ischial spine. At this point, the para-vaginal defect can be palpated. Beginning 1 cm proximal to the ischial spine, a series of non-absorbable sutures is placed in the white line. The

Fig. 14.11: Vaginal paravaginal repair. The sutures are then passed through the lateral pubocervical fascia and the underside of the vaginal skin.

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14

RETRO PUBIC PARAVAG INAL REPAIR

MESH VS. NO MESH

Through a low-transverse incision or laparoscopic ports, the retropubic space is opened. Addressing one side at a time, the bladder is pulled medially with blunt dissection, and simultaneously the surgeon has a finger in the vagina which is used to elevate the anterolateral vagina. The defect in the attachment of the vaginal fascia to the arcus tendineus is revealed. A series of sutures (delayed absorbable, or some surgeons prefer non-absorbable) is placed through the vagina (almost full thickness) and then into the fascia over obturator internus at the arcus tendineus. The sutures should extend from 1 to 2 cm anterior to the ischial spine, to the anterior limit of the fascial defect. Care is taken to avoid the obturator vessels, which lie lateral to the white line.

The success with permanent mesh in the management of abdominal hernias, and the success of mesh when used as sub-urethral tape for stress incontinence over the last two decades40 without major long-term complications, has encouraged the introduction of mesh for vaginal repair procedures. Meshes are biological or synthetic. Synthetic meshes are absorbable or non-absorbable. Synthetic meshes are classified on the basis of their physical characteristics.41 Type I mesh, which is used most frequently in vaginal reconstructive surgery, has a pore size greater than 90 microns and is constructed using monofilament fibres. The pore size allows macrophage access and fibrous tissue ingrowth. Type II and type III meshes are constructed using multifilament fibres, and have a small pore size that encourages bacterial colonisation. Type IV meshes are not used because they are relatively solid and inflexible. Type I mesh used in the anterior vaginal wall is either hand cut or factory shaped into multi-arm kits. A recent Cochrane review concluded that there is currently no evidence to support the widespread introduction of the use of mesh in the management of anterior vaginal wall prolapse, citing insufficient evidence that it reduces the incidence of recurrence.32 The same review concluded that when anterior vaginal repair is supplemented with absorbable mesh there are fewer recurrent cystocoeles, but data on morbidity and other clinical outcomes was lacking. More recently, in a prospective study of anterior transobturator mesh kit for the management of recurrent anterior vaginal prolapse, 53% of patients had ⱕ stage 1 prolapse 6 months to 2 years after surgery, and mesh exposure occurred in 19%, but the majority of women felt an improvement in their symptoms, which did not correlate with the anatomical outcome. The high incidence of adverse side effects resulting from mesh use has resulted in the publication by IUGA (International Urogynaecology Association) of a classification of complications specified as mesh contraction, prominence, exposure and extrusion. The classification also documents the site of the complication, namely the operation site, the urinary tract, the rectum and the presence of pain (Table 14.1).42

O the r Te c hniq ue s C O LPO SUSPENSIO N When stress incontinence is associated with cystocoele extending below the plane of the hymen, a colposuspension incorporating sutures slightly more laterally will give relief of stress incontinence and support of a low-to-mid cystocoele. This procedure will aggravate apical and posterior wall prolapse however and is not often used.

TRANSABDO MINAL WEDG E RESEC TIO N When carrying out an abdominal hysterectomy for a non– prolapse-related problem, in a patient with cystocoele, it is possible to perform a wedge resection of a triangle of vaginal skin from the anterior vagina. This procedure was popularised in USA and is only occasionally used, but can be useful.36

O utc o m e s fo r Surg e ry ANTERIO R C O LPO RRHAPHY VS. PARAVAG INAL REPAIR

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The assessment of outcomes for anterior vaginal wall surgery has relied on anatomical success as the primary outcome. Anatomic recurrence rates of around 30% are frequently described, but this includes women with stage I or II cystocoele who are not symptomatic. A prospective randomised study comparing abdominal para-vaginal repair to anterior colporrhaphy showed no difference between the two techniques in objective (around 70%) or subjective success rates (around 90%).37 If re-operation rates are taken as a proxy for symptomatic recurrence, only 3.4% at 2 years38 or 4.6% at 10 years39 require re-operation for cystocoele. Because surgeons are aware of the high rate of anatomic cystocoele recurrence, techniques using mesh have been developed.

ANTERIO R REPAIR VS. ANTERIO R REPAIR PLUS C O NTINENC E SURG ERY Should a patient with stage II or greater cystocoele and stress incontinence have anterior repair alone, repair plus sub-urethral tape43 or a colposuspension? There is currently no consensus. The addition of colposuspension to abdominal sacrocolpopexy reduces the incidence of stress incontinence,44 but has not been widely adopted.

PO STERIO R C O MPARTMENT PRO LAPSE Tears in the rectovaginal fascia, disruption of the perineal body, reduced function of the puborectalis muscle and enlargement of the urogenital hiatus all contribute to posterior vaginal

Table 14.1:

International Urogynaecological Association (IUGA) classification of mesh complications CATEGORY A (Asymptomatic)

B (Symptomatic)

C (Infection)

D (Abscess)

1

Vaginal: No epithelial separation. Include prominence (e.g. due to wrinkling or folding), mesh łbre palpation or contraction (shrinkage)

1A: Abnormal prosthesis or graft łnding on clinical examination

1B: Symptomatic e.g. unusual discomfort/pain; dyspareunia (either partner); bleeding

1C: Infection (suspected or actual)

1D = Abscess

2

Vaginal: Smaller ⱕ 1cm exposure

2A: Asymptomatic

2B: Symptomatic

2C: Infection

2D = Abscess

3

Vaginal: Larger > 1cm exposure, or any extrusion

3A: Asymptomatic 1–3Aa if no prosthesis or graft related pain

3B: Symptomatic 1–3B (b-e) if prosthesis or graft related pain

3C: Infection 1–3C/1–3D(b–e) if prosthesis or graft related pain

3D = Abscess

4

Urinary tract: Compromise or perforation. Including prosthesis (graft) perforation, łstula and calculus

4A: Small intraoperative defect e.g. bladder perforation

4B: Other lower urinary tract complication or urinary retention

4C: Ureteric or upper urinary tract complication

5

Rectal or bowel: Compromise or perforation including prosthesis (graft) perforation and łstula

5A: Small intraoperative defect (rectal or bowel)

5B: Rectal injury or compromise

5C: Small or Large bowel injury or compromise

5D = Abscess

6

Skin and/or musculoskeletal: Complications including discharge pain lump or sinus tract formation

6A: Asymptomatic, abnormal łnding on clinical examination

6B: Symptomatic e.g. discharge, pain or lump

6C: Infection e.g. sinus tract formation

6D = Abscess

7

Patient: Compromise including haematoma or systemic compromise

7A: Bleeding complication including haematoma

7B: Major degree of resuscitation or intensive care*

7C: Mortality* *(additional complication - no site applicable - S 0)

TIME (clinically diagnosed) T1: Intraoperative to 48 hours

T2: 48 hours to 2 months

T3: 2 months to 12 months

T4: over 12 months

SITE S1: Vaginal: area of suture line

S2: Vaginal: away from area of suture line

S3: Trocar passage Exception: Intra-abdominal (S5)

S4: other skin or musculoskeletal site

S5: Intra-abdominal

N.B. 1. Multiple complications may occur in the same patient. There may be early and late complications in the same patient. i.e. All complications to be listed. Tables of complications may often be procedure speciłc. 2. The highest łnal category for any single complication should be used if there is a change over time. (patient 888) 3. Urinary tract infections and functional issues (apart from 4B) have not been included.

CODE

-

T

-

S

Pelvic Organ Prolapse

General description

14

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14

prolapse. Unlike anterior colporrhaphy, corrective surgery is less likely to develop recurrence, but is more frequently associated with the development of dyspareunia. There is consensus amongst surgeons that techniques using mesh are rarely needed for the posterior vaginal wall. Rectovaginal fascia tears occur most frequently just above the perineal body, or just below the cervix, transversely. Lateral tears are also identified at the junction between the rectovaginal fascia and its attachment to the fascia over the puborectalis muscle. In practice, pre-operative evaluation rarely corresponds to intra-operative findings.

PO STERIO R C O LPO PERINEO RRHAPHY The term ‘posterior repair’ covers a range of procedures from perineal reconstruction, to complete pelvic floor repair including repair of hernia of the pouch of Douglas (enterocoele). The operation performed before the concept of fascial repair45,46 was to approximate puborectalis together in the midline, which almost always caused a constriction and dyspareunia. The objectives of posterior repair are:

Fig. 14.12: Posterior colpoperineorrhaphy. Diamond shaped incision in posterior vaginal wall.

1. Treatment of rectocoele by repair of the rectovaginal fascial defect. 2. Reconstruction of the perineal body. 3. To reduce the size of the urogenital hiatus—not needed very often. Pre-operatively the lower rectum should be empty, if necessary using a small enema. A pair of Littlewoods forceps is placed at the posterior end of the labium minus bilaterally. A small Kocher forceps is placed on the vaginal wall in the midline, 4 cm from the introitus. The two lateral tissue forceps are drawn outwards and the skin of the perineum is put on the stretch. A thin layer of the stretched skin is excised with a scalpel, in a diamond shape, extending on to the perineal skin. (See Fig. 14.12) If there is no indication to reduce the size of the introitus, a vertical rather than horizontal incision is used. Two pairs of forceps are attached to the cut edge of the vagina near the midline and pulled posteriorly. The midline vaginal incision is extended with scissors or a scalpel to 3 cm below the cervix. The incision must be made with care, as the anterior wall of the rectum or the anal canal may be closely adherent to the vaginal wall. Using sharp dissection, the vaginal walls are separated from the underlying rectovaginal fascia and the rectum, as far laterally as the attachment to the fascia over the obturator internus (see Fig. 14.13). Rectal examination (a ‘urology prostrate drape’ can greatly help and avoid the need to keep changing gloves) will demonstrate the fascial defects, which can then be repaired. If a large enterocoele is identified (containing loops of small bowel or rarely a sigmoidocoele), it is sensible to open, mobilise and excise the peritoneal sac. The sac is then closed in a double layer of vicryl suture (see Fig. 14.14). If the enterocoele is small (less than 3 cm) there is no need to open the sac, as long as it is possible to close the fascial defect over it. If there is a need to 268

Fig. 14.13: Colpoperineorrhaphy operation. In this operation, the rectovaginal space has been opened up. On each side of the space, the rectal pillars can be seen; the tissue held down in the midline with forceps is the cut prerectal fascia.

provide apical support other techniques are used (see later in this chapter). To repair the fascial defect, start with the transverse defect, which is almost always present where rectovaginal fascia is separated from the uterosacral ligaments, and work towards the

Pelvic Organ Prolapse

14

Fig. 14.14: Colpoperineorrhaphy operation. The prerectal fascia is reconstituted by a tier of imbricating sutures.

perineum (some surgeons prefer to start at the perineum). If possible, a two-layer technique is used, starting with sitespecific repair and then using a second continuous layer if there is sufficient mobility and vaginal capacity. This lamination will hopefully provide additional strength as it does with a construction beam. If a patient has a pelvic floor with almost no support, and a large levator hiatus, it is necessary to add sutures laterally and further up the vagina to create a levatorplasty. This inevitably produces a ridge of tissue in the middle of the vagina. To minimise the prominence of the ridge, it is necessary to reconstruct the perineal body more than normally, using a combination of lateral incision of the perineal muscles and a further layer of sutures. The posterior vaginal wall is now sutured down to the hymen (see Fig. 14.15). Perineoplasty is performed in three layers of interrupted vicryl sutures, after sufficient lateral incision in the perineal muscles to allow lengthening of the perineum (see Fig. 14.16).

Fig. 14.15: Colpoperineorrhaphy operation. Posterior vaginal wall closure is carried out caudally as far as the apex of the perineal body.

Discussion Rectocoele repair will result in resolution of symptoms of straining and incomplete emptying in the majority of patients,47 it will not improve patients with slow transit constipation and other primary colorectal problems. Transvaginal repair is associated with less risk of recurrent prolapse than transanal repair.48 A randomised study compared three techniques, posterior colporrhaphy, site-specific repair and site-specific repair with porcine graft inlay. There were no differences in subjective (15%) failure rate. At 1 year however, there was a lower objective failure rate in the posterior colporrhaphy group as compared to the graft inlay group.49

Fig. 14.16: Colpoperineorrhaphy operation. The sub-cuticular method of suturing the tissues of the perineum is shown.

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APIC AL PRO LAPSE

14

Descent of the apex of the vagina (loss of level I support) happens when the uterosacral ligament, the cardinal ligament and the upper fascial attachments of the anterior and posterior vaginal wall give way. It happens very frequently in association with cystocoele and rectocoele. The management of apical prolapse depends on whether hysterectomy has been carried out. There is great variation amongst surgeons as to which procedure to use – this bears witness that no one operation gives a perfect result, and it is necessary to individualise surgery. Hysterectomy itself is not a treatment for vaginal apex prolapse. It has been shown for example that sacrospinous fixation with or without hysterectomy made no difference to the incidence of recurrent vault prolapse.50

Va g ina l O pe ra tio ns to Suppo rt the Va ult SAC RO SPINO US FIXATIO N The following description is for a patient who has had a previous total abdominal hysterectomy. The vagina is incised in the midline. If anterior vaginal repair is needed, this is carried out first, but the vaginal skin incision is not closed. The skin incision is then extended from the apex of the vagina down the midline of the posterior vaginal wall, using the same incision as for a posterior vaginal repair/perineoplasty. If an enterocoele is present, the pouch of Douglas hernial sac is identified, opened, mobilised, excised and closed. The ‘angles’ of the vaginal vault are identified and marked with a suture. The next step is the mobilisation of the right para-rectal space to gain access to the sacrospinous ligament. The tissue between the lateral side of the rectum and the sacrospinous ligament is the rectal pillar, and it is necessary to create a window in the rectal pillar to gain access to the ligament. Some surgeons are happy to pass sutures through the sacrospinous ligament using palpation alone, but the majority of surgeons use two or three single-bladed retractors to support the rectum medially, the peritoneum anteriorly and para-vaginal tissues laterally. The dissection continues until the glistening fibres of the ligament are clearly visible. The sacrospinous ligament runs posteromedially from the ischial spine to the lateral border of the sacrum and coccyx. The pudendal nerve and vessels run through Alcock’s canal posterior to the ischial spine, the sciatic nerve runs superiolaterally to the SSL, and superior to the ligament are the inferior gluteal vessels. The safe place to pass a suture through the ligament is therefore two fingers’ breadth medial to the spine, without allowing the suture to go deep to the ligament or superior to the ligament. Two sutures of delayed absorbable sutures are sited using a specially designed needle passer (miya hook or capio). (see Fig. 14.17) Permanent suture can cause pain that only settles if the suture is removed. One end of each of the sutures is brought 270

Internal iliac artery Sacral plexus

Inferior gluteal nerve and vessels

Fibromuscular coccygeal sacrospinal ligament

Pudendal nerve and vessels Safe pararectal space

Fig. 14.17: Sacrospinous łxation.

through the complete thickness of the vaginal vault. The other end is sutured and tied into the underside of the vaginal vault skin/fascia and is then brought through the vaginal skin so that at the end of the procedure pulling on the free end of each of the two sutures will act like a pulley. The posterior vaginal repair is completed, leaving enough room in the fascial repair for the vault to invert and reach the SSL. The skin of the vagina is pushed upwards towards the sacrospinous ligament and the sutures are tied without tension, even if the vault does not physically reach the SSL. If the sutures are under tension, they are more likely to give way and very likely to cause disabling buttock pain. The procedure can be done in one or both sides.

HIG H UTERO SAC RAL LIG AMENT SUSPENSIO N This procedure to support the vaginal apex is rarely performed in Europe, but is frequently used as an alternative to sacrospinous fixation in the USA. The skin over the vaginal vault is incised in the midline, the peritoneum of the enterocoele sac is opened and mobilised from the surrounding structures, posteriorly, up to the level of adherence to the front wall of the rectum. Small bowel adhesions are mobilised and the small bowel packed away, superiorly. Allis’ clamps are used to hold the free edge of the vagina at 5 and 7 o’clock, where the remnants of the uterosacral ligaments are thought to be. Using traction, the uterosacral ligament is identified and the ureter is palpated laterally and the rectum medially. Two or three delayed absorbable sutures are placed in each uterosacral ligament but not tied. The distal 2 cm of the uterosacral ligaments are sutured together in front of the rectum to obliterate the Pouch of Douglas. The previously placed delayed absorbable sutures are then brought through the fascia and full thickness of the vagina and tied. The technique will need to be evaluated against other methods of providing apical support, but the incidence of per operative ureteric injury is around 2%, despite intraoperative cystoscopy.

Pelvic Organ Prolapse

THE MANC HESTER (FO THERG ILL) O PERATIO N The objectives of this procedure are: 1. To amputate the cervix leaving approximately 7 cm of uterus. 2. Approximation of the ‘connective tissue on either side of the cervix’ (i.e. the uterosacral and cardinal ligaments), in front of the cervix. This shortens these ligaments and thus elevates and displaces the cervix posteriorly. This backward displacement encourages anteversion and helps prevent prolapse. The operation is almost always combined with anterior repair, posterior vaginal repair and perineoplasty. Preliminary preparation is exactly the same as for the operation of anterior colporrhaphy. The patient is placed in the lithotomy position. The cervix is grasped with vulsellum forceps, and dilated and endometrial curettage performed. The reason for dilating the cervix is that the repair of the cervix can be carried out more easily after the cervical canal has been dilated. The vaginal incision is in the shape of an inverted tennis racquet with the anterior apex, 3 cm below the urethral opening, encircling the cervix. The classical description of Fothergill’s four points makes the operation unnecessarily complicated. The more vaginal skin that is removed lateral to the cervix, the greater the degree of vaginal shortening which must therefore be avoided. It is easy to remove additional skin later in the operation, but you can never put it back once it has been excised. The vaginal skin is mobilised as for anterior colporrhaphy. The vaginal skin lateral to the cervix is also mobilised to expose the cardinal ligaments (see Fig. 14.18). The bladder (and therefore the ureters) is mobilised, including division of the bladder pillars, but the peritoneum anteriorly is not opened. If needed anterior vaginal repair is carried out. The cervix is now pulled upwards and forwards to expose the posterior fornix. The vaginal skin is mobilised by sharp and blunt dissection from the pouch of Douglas and from the uterosacral ligaments. The pouch of Douglas is opened, and if an enterocoele sac is present, it is mobilised to the level of the rectum recognisable by longitudinal muscle fibres. The uterosacral/cardinal ligaments on either side of the cervix can now be seen (they are fused for 2 cm from the cervix). The ligaments and para-cervical tissue to just below the uterine vessels are clamped, divided and sutured for haemostasis. A second suture using a double bite of the avascular pedicle is taken, and left long without cutting off the needle. The cervix is amputated using needle diathermy or scalpel, just below the internal os (Fig. 14.19). The next step is to suture the vaginal skin to the back of the cervix. The classical description is to use the Bonney–Sturmdorf suture so that the vaginal skin is enfolded into the cervical canal. This encourages stenosis of the cervix. Therefore, simply suture the vaginal skin edge to the outer edge of the cut surface of the cervix, leaving the cut edge of the cervix to heal as with LLETZ.

14

Fig. 14.18: Manchester operation. The left cardinal ligament is exposed, clamped, cut and ligated.

To suture the cardinal/uterosacral ligaments to the anterior lip of the cervix, the classical description is by using Fothergill’s key suture. This enters the vaginal skin at the level of Fothergill’s lateral point and transfixes a good bite of the cut cardinal ligament pedicles. The needle next enters the cervical canal by being passed from without inwards through the full substance of the anterior cervical muscle near the midline at 12 o’clock. At this stage, the edges of the two lateral flaps are picked up to constitute the anterior part of the Sturmdorf suture. The needle is now re-passed from within outwards and through the cardinal ligament pedicle of the other side and finally out at Fothergill’s other lateral point (see Fig. 14.20). As a modification of this technique, instead of using Fothergill’s key suture, I suture the uterosacral/cardinal ligament complex to the front of the cervix using an overlap, as might be used to repair the anal sphincter. The vaginal skin is sewn separately to the anterior edge of the cervix. After excising redundant anterior vaginal wall skin, the vagina is closed with continuous 2/0 vicryl.

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Fig. 14.20: Manchester repair. The posterior lip of the cervix is re-epithelialised with vaginal skin.

Fig. 14.19: Manchester operation. After cutting and ligating both cardinal ligaments, the cervix is amputated at a high level.

ABDO MINAL SAC RO C O LPO PEXY

272

Suspension of the vaginal vault from the sacrum using mesh can be done laparoscopically or through laparotomy. Vaginal placement of the mesh is associated with a higher chance of infection and mesh erosion and is not recommended. The patient is placed in Lloyd Davis leg supports. A swab on a stick is placed in the vagina and a rectal sizer is placed in the rectum. Adhesions throughout the pelvis are freed. The vaginal vault is identified and the peritoneum is opened in order to mobilise the bladder for at least 3 cm anteriorly. Posteriorly the rectum is mobilised for at least 7 cm—some surgeons prefer to free the posterior vaginal surface as far as the pelvic floor. Attention is turned to the sacrum. After identification of the pelvic structures including the course of the ureter, the peritoneum over the sacral promontory is divided and the incision in the peritoneum is continued across the right side of the pelvis to the vaginal vault. Pre-sacral tissues are gently dissected over S1 S2, trying not to destroy the para-sympathetic nerves and attempting to avoid causing bleeding from the median sacral vessels and the iliac veins.

The mesh is placed over the vaginal vault and sutured using at least three pairs of interrupted prolene sutures posteriorly, one pair of sutures at the vault and two pairs of sutures anteriorly. Sutures are placed using figure of eight bites of the full thickness of the vagina but not entering the vaginal lumen if possible. The mesh is trimmed and placed across the pelvis without tension. Two or three sutures are placed through the median sacral ligament to attach the mesh. The peritoneum is closed from the sacrum down to the pelvis and across the vaginal vault in order to achieve complete coverage of the mesh.

Discussion Abdominal sacrocolpopexy is used as a treatment for vaginal vault prolapse, additionally it can be used at the time of hysterectomy as a measure to prevent future vault prolapse. Sacrospinous fixation is also used as treatment for vaginal vault prolapse and can be used at the time of hysterectomy to prevent future vaginal vault prolapse. A Cochrane review32 concluded that abdominal sacrocolpopexy was associated with a lower rate of recurrent vault prolapse (0–6%) and less dyspareunia, but there was no difference in the reoperation rates for prolapse. A systematic review for the NICE guidelines51 showed that the median mesh erosion rate was 4.0% for non-absorbable synthetic mesh. Long-term effects of sacrocolpopexy include an increased incidence of obstructed defaecation52 and cystocoele. Some degree of cystocoele is very frequently identified after vault suspension procedures, but most are asymptomatic.53

Pelvic Organ Prolapse

UTERINE PRESERVATIO N O PERATIO NS FO R APIC AL PRO LAPSE It is very difficult to establish from literature review why hysterectomy was introduced to the management of uterine prolapse and has been the mainstay of surgical management since the 1950s. The uterus can be supported abdominally or vaginally for the management of POP. Abdominal operations: The uterus has been suspended from the anterior abdominal wall54 but this was abandoned because it predisposed to a high incidence of posterior prolapse. Alternatively the fundus of the uterus was suspended from the sacrum.55 More recently, laparoscopic techniques have used mesh sutured around the cervix suspended from the sacrum and these await evaluation.56 The Manchester operation was first performed in 1888 by Archibald Donald in Manchester. One of his trainees, Edward Fothergill, modified the operation by adding parametrial fixation.57 It was performed extensively until the 1950s when it was replaced by vaginal hysterectomy—the reason for the change to hysterectomy did not appear to be evidence based. A few studies comparing vaginal hysterectomy with Manchester repair report similar outcomes with less morbidity58 and more recently De Boer59 showed no middle compartment prolapse after Manchester repair at 1 year. All procedures that provide support to the apex of the vagina alone will need to be combined with procedures to repair vaginal fascial defects and rebuild the perineum if needed.

C O LPO C LEISIS One surgical option for a patient with complete collapse of the pelvic floor, often associated with ulceration of the skin, with or without previous hysterectomy in an elderly patient who is no longer having intercourse, is colpocleisis. This procedure may be performed under regional or local anaesthesia. Several techniques are described, two of which are described below. Stress urinary incontinence is a problem postoperatively due to occult incontinence, which can be prevented by siting a sub-urethral tape.60

Partial Colpocleisis If the patient has not had a hysterectomy, a rectangular incision extending from the cervix to 3 cm below the urethra is made in the anterior vaginal wall and the vaginal epithelium is stripped from the underlying pubocervical fascia. A similar rectangular incision is made in the posterior vaginal wall from the cervix to the perineum, leaving a bridge of vagina 3 cm wide on each side and sufficient vaginal epithelium in front and behind the cervix to allow the first row of sutures to bury the cervix. The vagina is now sutured across the front of the cervix, and the entire anterior vaginal wall is sutured to the posterior vaginal wall in a series of sutures. Laterally there is a tunnel for cervix secretions to drain.

Total Colpocleisis If the patient has had total hysterectomy, a circumferential incision is made round the base of the prolapse at the level of the hymen. All the vaginal epithelium is stripped off, from the apex of the prolapse to the circumferential incision. A series of delayed absorbable sutures is placed starting with a purse string at the apex of the prolapse (not opening the enterocoele, if possible) and gradually obliterating the vagina. It is wise to place some sutures at the bladder neck to try and prevent stress incontinence, and a modified colpoperineorrhaphy can also be performed. At the lower end of the vagina, the vaginal skin edges are sutured.

14

Re fe re nc e s 1. Haylen BT, De Ridder D, Freeman RM, et al. An International Urogynaecological Association (IUGA)/International Continence Society (ICS) joint report on the terminology for female pelvic loor dysfunction. Int Urogynecol J. 2010;21:5–26. 2. Swit S, Woodman P, O’Boyle A, et al. Pelvic Organ Support Study (POSST): he distribution, clinical deinition, and epidemiologic condition of pelvic organ support defects. Am J Obstet Gynecol. 2005;192:795–806. 3. Olsen AL, Smith VJ, Bergstrom, Colling JC, Clark AL. Epidemiology of surgically managed pelvic organ prolapse and urinary incontinence. Obstet Gynecol. 1997;89:501–6. 4. Brubaker L, Bump R, Jacquetin B, et al. Pelvic Organ Prolapse. Incontinence: 2nd International Consultation on Incontinence. 2nd ed. Plymouth: Health Publication Ltd.; 2002, 243–65. 5. Walker GJA, Gunasekera P. Pelvic organ prolapse and incontinence in developing countries: review of prevalence and risk factors. Int Urogynaecol J. 2011;22:127–35. 6. Jones KA, Shepherd JP, Oliphant SS, Wang L, Bunker CH, Lowder JL. Trends in inpatient prolapse procedures in the United States 1979–2006. Am J Obstet Gynecol. 2010;202(5):501e1–7. 7. Handa VL, Garrett E, Hendrix DO, Gold E, Robbins J. Progression and remission of pelvic organ prolapse: A longitudinal study of menopausal women. Am J Obstet Gynecol. 2004;190:27–32. 8. Lukacz ES, Lawrence JM, Contreras R, Nager CW, Luber KM. Parity mode of delivery and pelvic loor disorders. Obstet Gynecol. 2006;107:1253-60. 9. Altman D, Falconer C, Cnattingius S, Granath F. Pelvic organ prolapse surgery following hysterectomy on benign indications. Am J Obstet Gynecol. 2008;198(5):572e1–6. 10. Pendergrass PB, Belovicz MW, Reeves CA. Surface area of the human vagina as measured from vinyl Polysiloxane casts. Gynecol Obstet Invest. 2003;55:110–3. 11. Karam JA, Vazquez, Lin VK, Zimmern PE. Elastin expression and elastic ibre width in the anterior vaginal wall of postmenopausal women with and without prolapse. BJU Int. 2007;100:346–50. 12. DeLancey JOL. he anatomy of the pelvic loor. Curr Opin Obstet Gynecol. 1994;6:313–6. 13. Steensma AB, Konstantinovic ML, Burger CW, de Ridder D, Timmerman D, Deprest J. Prevalence of major levator abnormalities in symptomatic patients with an underactive pelvic loor contraction. Int Urogynecol J. 2010;21:861–7. 14. Spence-Jones C, Kamm MA, Henry MM, et al. Bowel dysfunction: a pathogenic factor in uterovaginal prolapse and

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16.

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urinary stress incontinence. Br J Obstet Gynaecol. 1994;101(2): 147–52. Weber AM, Walters MD, Piedmonte MR, Ballard LA. Anterior colporrhaphy: A randomized trial of three surgical techniques. Am J Obstet Gynaecol. 2001;185(6)1299–304. Lowder JL, Frankman EA, Ghetti C, et al. Lower urinary tract symptoms in women with pelvic organ prolapse. Int Urogynaecol J. 2010;21:665–72. Nguyen JK, Bhatia NN. Resolution of motor urge incontinence ater surgical repair of pelvic organ prolapse. J Urol. 2001;166:2263–66. Foster RT, Barber MD, Parasio MF, Walters MD, Weidner AC, Amundsen CL. A prospective assessment of overactive bladder symptoms in a cohort of elderly women who underwent transvaginal surgery for advanced pelvic organ prolapse. Am J Obstet Gynecol. 2007;197(1):82e1–4. Rosenzweig BA, Soici AR, homas S, Bhatia NN. Urodynamic evaluation of voiding in women with cystocele. J Repro Med. 1992;37(2):162–6. Srikrishna S, Robinson D, Cardozo L. Ringing the changes in evaluation of urogenital prolapse. Int Urogynecol J. 2011;22:171–5. Raza-Khan F, Cunkelman J, Lowenstein L, Shott S, Kenton K. Prevalence of bowel symptoms in women with pelvic loor disorders. Int Urogynaecol J. 2010;21:933–8. Pauls RN, Kleeman SD, Karram MM. Female sexual dysfunction; principles of diagnosis and therapy. Obstet Gynecol Surv. 2005;60:196–205. Meston CM, Derogatis LR. Validated instruments for assessing female sexual function. J Sex Marital her. 2002;28(Suppl 1):155–64. haker R, Chawler S, Scheer I, Barrett G, Sultan A. Sexual function following pelvic loor surgery. Int J Gynaecol Obstet. 2008;102(2): 110–4. Weber AM, Walters MD, Piedmonte MR. Sexual function and vaginal anatomy in women before and ater surgery for pelvic organ prolapse and urinary incontinence. Am J Obstet and Gynecol. 2000;182:1610–5. Strohbehn K, Jakary JA, DeLancey JOL. Pelvic organ prolapse in young women. Obstet Gynecol. 1997;90(1):33–6. Baden WF, Walker TA. Genesis of the vaginal proile: A correlated classiication of vaginal relaxation. Clin Obstet Gynecol. 1972;15(4):1048–54. Beecham CT. Classiication of vaginal relaxation. Am J Ostet Gynecol. 1980;136(7):957–8. Bump RC, Mattiasson A, Bo K, et al. he standardization of terminology of female pelvic organ prolapse and pelvic loor dysfunction. Am J Obstet Gynecol. 1996;175:10–7. Ibeanu OA, Chesson RR, Sandquist D, Perez J, Santiago K, Nolan TE. Hypertrophic cervical elongation: clinical and histological correlations. Int Urogynaecol. 2010;21:995–1000. Abdool Z, haker R, Sultan AH, Oliver RS. Prospective evaluation of outcome of vaginal pessaries versus surgery in women with symptomatic pelvic organ prolapse. Int Urogynaecol J. 2011;22:273–8. Maher C, Feiner B, BaesslerK, Glazener CMA. Surgical management of pelvic organ prolapse in women (review). he Cochrane Library issue 8; 2010. Larson KA, Hsu Y, Chen L, Ashton-Miller JA, DeLancey JO. Magnetic resonance imaging-based three-dimensional model of anterior vaginal wall position at rest and maximal strain in

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women with and without prolapse. Int Urogynaecol J. 2010;21: 1103–9. Kelly HA. J Amer Med Assoc. 1886;7:666. White GR. Cystocele : a radical cure by suturing lateral sulci of vagina to white line of pelvic fascia. JAMA. 1909;853:1707–10. Macer GA. Transabdominal repair of cystocele a 20 year experience, compared with the traditional vaginal approach. Am J Obstet Gynecol. 1978;131:203–7. Minassian V, Parekh M, Poplawsky D, Litzt L. Randomized controlled trial comparing anterior colporrhaphy to abdominal paravaginal defect repair for anterior vaginal wall prolapse. Int Urogynecol J. 2010;21(suppl 1):S81–2. Kapoor DS, Nemcova M, Pantazis K, Brockman P, Bombieri L, Freeman RM. Reoperation rate for traditional anterior repair: analysis of 207 cases with a median 4-year follow-up. Int Urogynecol J. 2010;21:27–31. Denman MA, Gregory WT, Boyles SH, Smith V, Edwards SR, Clark AL. Reoperation rate 10 years ater surgically managed pelvic organ prolapse and urinary incontinence. Am J Obstet Gynecol. 2008;198:555e1–5. Ulmsten U, Henriksson L, Johnson P, Varhos G. An ambulatory surgical procedure under local anaesthesia for treatment of female urinary incontinence. Int Urogynecol J Pelvic Floor Dysfunct. 1996;7:81–6. Amid PK. Classiication of biomaterials and their related complications in abdominal wall surgery. Hernia. 1997;1:15–21. Haylen BT, Freeman RM, Swit SE, et al. An international Urogynecological Association/International continence Society Joint terminology and classiication of complications related directly to the insertion of prostheses (meshes, implants, tapes) or grats in female pelvic loor surgery. Int Urogynecol J. 2011; 22:3–15. Schierlitz L, Dwyer P, Rosamilia A, Murray C, homas E, Taylor N, et al. A prospective randomised controlled study comparing vaginal prolapse repair with and without tension free vaginal tape (TVT) in women with severe pelvic organ prolapse and occult stress incontinence (Abstract number 114). Neurourol Urodynam. 2007;26(5):743–4. Brubaker L, Nygaard I, Richter HE, Visco A, Weber AM, Cundif GW, et al. Two-year outcomes ater sacrocolpopexy with and without Burch to prevent stress urinary incontinence. Obstet Gynaecol. 2008;112(1):49–55. Richardson AC. he rectovaginal septum revisited: Its relationship to Rectocele and its importance in rectocele repair. Clin Obstet Gynecol. 1993;36(4):976–83. Richardson AC. he anatomic defects in rectocele and enterocele. J Pelvic Surg. 1995;1(4):214–21. Gustilo-Ashby AM, Paraiso MF, Jelovsek JE, Walters MD, Barber MD. Bowel symptoms 1 year ater surgery for prolapse: further analysis of a randomized trial of rectocele repair. Am J Obstet Gynecol. 2007;197(1):76e1–5. Nieminen K, Hiltunen KM, Laitinen J, Oksala J, Heinonen PK. Transanal or vaginal approach to rectocele repair: a prospective randomized pilot study. Dis Colon Rectum. 2004;47:1636–42. Paraiso MF, Barber MD, Muir TW, Walter MD. Rectocele repair: a randomized trial of three surgical techniques including grat augmentation. Am J Obstet Gynecol. 2006;195(6):1762–71. Brummen HJ, Van de Pol G, et al. Sacrospinous hysteropexy compared to vaginal hysterectomy as primary surgical treatment for a descensus uteri. Int Urogynaecol J. 2003;14:350–5.

Pelvic Organ Prolapse 51. Jia X, Glazener C, Mowatt G, et al. Systematic review of the eicacy and safety of using mesh in surgery for uterine or vaginal vault prolapse. Int Urogynecol J. 2010;21:1413–31. 52. Forsgen C, Zetterstrom J, Zhang A, Iliadou A, Lopez A, Altman D. Anal incontinence and bowel dysfunction ater sacrocolpopexy for vaginal vault prolapse. Int Urogynecol J. 2010;21:1079–84. 53. Holley RL, Varner RE, Gleeson BP, et al. Recurrent pelvic support defects ater sacrospinous ligament ixation for vaginal vault prolapse. J Am Coll Surg. 1995;180:444–8. 54. Kelly HA. Incontinence of urine in women. Urol Cutan Rev. 1913;17:291–3. 55. Arthure HGF, Savage D. Uterine prolapse and prolapse of the uterine vault treated by sacral hysteropexy. J Obstet Gynecol Br Comwlth. 1957;64:355–60. 56. Price N, Slack A, Jackson SR. Laparoscopic hysteropexy: the initial results of a uterine suspension procedure for uterovaginal prolapse. Br J Obstet Gynecol. 2010;117(1):62–68.

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Fothergill WE. Clinical demonstration of an operation for prolapsus uteri complicated by hypertrophy of the cervix. Br Med J. 1913;1:762–3. 58. homas AG, Brodman ML, Dottino PR, Bodian C, Friedman F Jr, Bogursky E. Manchester procedure vs vaginal hysterectomy for uterine prolapse. J Repro Med. 1995;40(4):299–304. 59. De Boer TA, Milani AL, Kluivers KB, Withagen MI, Vierhout ME. he efectiveness of surgical correction of uterine prolapse: cervical amputation with uterosacral ligament plication (modiied Manchester ) versus vaginal hysterectomy with high uterosacral ligament placation. Int Urogynecol J. 2009;20(11): 1313–9. 60. Smith A, Karp D, Lefevre R, et al. Lefort colpocleisis and stress incontinence: weighing the risk of voiding dysfunction against sling placement. Int Urogynecol J. 2010;21(suppl 1): S411.

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SECTION

G yna e c o lo g ic a l C a nc e r Surg e ry

SEC TIO N O UTLINE 15. Vulva l a nd Va g ina l Ca nc e r ... 279 16. Ute rus a nd Ce rvix Ca nc e r ... 293 17. Ova ria n a nd Tub a l Ca nc e r ... 321

D

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Vulva l a nd Va g ina l C a nc e r

15

John Butler, John H. Shepherd

Intro duc tio n Malignant disease of the vagina and vulva are rare conditions, and it is essential that these patients are managed in centres with surgical, radiological, pathological and nursing expertise. Malignant disease of the vulva is the fourth most common malignancy of the female genital tract and accounts for 3% of gynaecological malignancy. There are around 1000 new cases each year in the United Kingdom and 400 deaths. Many vulval cancers occur on the background of pre-invasive disease. In the United Kingdom, there are around 250 new cases of primary vaginal carcinoma each year.1 The median age of diagnosis is 63 but the disease can affect all age groups including the very young and elderly. Vaginal adenocarcinomas in younger women are usually of clear cell type, and in women under 30 years of age there is usually a history of vaginal adenosis due to in utero diethylstilbestrol exposure (Fig. 15.1). In infancy,

malignant disease of the vagina or cervix is likely to be rhabdomyosarcoma: sarcoma botryoides with a characteristic grapelike appearance.

Vulva l Intra - Epithe lia l Ne o pla sia Vulval intra-epithelial neoplasia (VIN) is a pre-malignant condition of the vulva with two sub-groups: differentiated VIN (dVIN) and usual VIN (uVIN). uVIN is associated with HPV and is more common in younger women, whereas dVIN is predominantly seen in older women and not related to HPV infection. VIN may progress to vulval cancer and a variety of treatment modalities have been used in order not only to treat disease, but also reduce treatment-related morbidity. The malignant potential of dVIN is greater than uVIN and increases with age.2 The risk of invasion is around 9% in untreated VIN3 and 3.3% after treatment. Spontaneous regression occurs in 1.3%.3 When assessing VIN, it is essential that the vagina, cervix and anal canal are examined as there may be similar changes elsewhere. The progression rate of VIN to invasive cancer is substantially greater than for CIN.4

INVESTIG ATIO N When there is hyperkeratosis, colposcopy of the vulva is of limited value because the keratin prevents assessment of the capillary vascular pattern, which is a key feature in the assessment of cervical intra-epithelial neoplasia. Within the vestibule and adjacent thin skin colposcopy is usually feasible using acetic acid. Toludine blue may be utilised to target biopsy sites.5 Obtaining material for histological examination is essential to identify invasion and margins, as naked eye assessment of the margins is unreliable. For more widespread lesions, multiple drill biopsies should be performed using a Keyes punch biopsy.

TREATMENT CM

1

2

3

4

5

6

7

8

Fig. 15.1: Adenocarcinoma of the vagina. Clear cell carcinoma of the vagina arising in association with vaginal adenosis in a young woman aged 29. Hysterocolpectomy performed by the synchronous combined technique was followed by immediate split skin graft to the pelvic cavity.

A variety of treatment modalities have been used to treat VIN: local excision, total vulvectomy, skinning vulvectomy, photodynamic therapy, laser ablation and imiquimod.6,7 The choice of treatment depends on the location of disease, surrounding skin tissue quality, cosmesis and previous treatments. Radical vulvectomy is rarely indicated for VIN, and historically there has been significant overtreatment of

Section D | Gynaecological Cancer Surgery

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pre-invasive lesions, as described in earlier editions of this and other recognised text books. Where there is extensive involvement of the vulva, a skinning vulvectomy may be performed. The skin alone may be removed preserving the contour of the underlying fat and sparing the glans of the clitoris.8 On occasion, if local skin flaps cannot be used, skin grafts may be required.9,10 Following extensive grafting forced immobilisation may be necessary to reduce physical stress on the operative sites. Alternative treatments are topical cytotoxic agents, the immune response modifier imiquimod and laser ablation therapy. Laser therapy to the vulva is often extremely painful. Invasion must be excluded prior to any non-excisional technique.

Table 15.1: Stage I

FIGO staging of carcinoma of the vulva

Tumour conłned to the vulva

IA

Lesions Ł2 cm in size, conłned to the vulva or perineum and with stromal invasion Ł1.0 mm*, no nodal metastasis

IB

Lesion >2 cm in size or with stromal invasion >1.0 mm*, conłned to the vulva or perineum, with negative nodes

Stage II

Tumour of any size with extension to adjacent perineal structures (1/3 lower urethra, 1/3 lower vagina, anus) with negative nodes

Sage III

Tumour of any size with or without extension to adjacent perineal structures (1/3 lower urethra, 1/3 lower vagina, anus) with positive inguino-femoral lymph nodes

IIIA

(i) With 1 lymph node metastasis (—5 mm), or (ii) 1–2 lymph node metastasis(es) (16 months.56 Further prospective evaluation is awaited. Patients with indolent leiomyosarcoma may benefit from an aggressive surgical approach as well as hormonal therapy with medroxyprogesterone, aromatase inhibitors, or mifepristone, a progesterone antagonist. Hormonal manipulation of the progesterone pathway possibly results in the longer disease control compared to oestrogen pathway interference.46 Trials using hormonal agents against expectant management are ongoing.

19

FUTURE DIREC TIO NS Research interest at present is focused on the use of the novel agents that have recently found their way into the management of other malignancies, such as agents targeting the VEGF pathway (bevacizumab), mTOR inhibitors (temsirolimus and everolimus), tyrosine kinase inhibitors (sunitinib) and EGFR inhibitors (gefitinib and erlotinib)57; the publication of results in peer-reviewed format are awaited for most of these. Despite some endometrial adenocarcinomas over-expressing HER2, trastuzumab did not exhibit significant activity as a single agent.58 In uterine sarcoma, recent research activity has focussed on the promising activity of gemcitabine and docetaxel in leiomyosarcoma. Trabectedin, a novel anti-neoplastic agent derived from the marine organism Ecteinascidia turbinata has also generated interest.59 Tyrosine kinase inhibitors such as imatinib, sunitinib and pazopanib have not shown significant activity in uterine sarcoma.60,61

C a nc e r o f the O va rie s Cancers of the ovary are chemotherapy sensitive and its role in the adjuvant and metastatic settings is well established. Fallopian tube and primary peritoneal carcinoma are treated as epithelial ovarian carcinoma.

EPITHELIAL MALIG NANC IES

Early Stage Disease Even very early stage disease (stage IC or any stage I high grade tumour) has a high chance of disease recurrence.62 The pivotal trials for the benefit of adjuvant chemotherapy in early stage disease were the MRC-ICON1 and EORTC-ACTION trials comparing platinum-based adjuvant chemotherapy to standard follow-up with treatment at progression.63 In the combined analysis, the median progression-free survival at 5 years improved from 65% for standard follow-up to 76% for adjuvant chemotherapy (HR = 0.64, 95% CI 0.50–0.82, p = 0.001), while overall survival improved from 74% to 82%, respectively. Despite the criticism of these trials regarding the heterogeneity of chemotherapy regimen used, eligibility criteria and requirements for surgical staging, they nonetheless established platinum-based adjuvant chemotherapy as the standard of care for patients with the following: stage IB grade 2 and 3, stage IC, stage 2 and all stage I clear cell carcinomas. 347

Section E | Aspects of Multidisciplinary Care in Gynaecology

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Based on the findings in late stage disease, the addition of paclitaxel has become standard in many centres without a randomised evidence base. The GOG-157 compared 3 to 6 cycles of carboplatin plus paclitaxel with a suggestion that 3 cycles are associated with an inferior progression-free survival, while 6 cycles are associated with a marked increase in toxicity.64 A patient who is not fit or unwilling to accept the toxicity of combination chemotherapy should therefore be offered six cycles of single agent carboplatin.

Late Stage Disease

348

Until the early 1990s, the standard of care for patients with late stage disease had been cisplatin and cyclophosphamide, given immediately after surgery.65 The GOG-111 and OV-010 trials showed the superiority of cisplatin and paclitaxel over cisplatin and cyclophosphamide in terms of progression-free and overall survival.66,67 The GOG trial showed an improvement in median progression-free survival from 13 to 18 months (HR = 0.7; 95% CI 0.5–0.8; p < 0.001) and overall survival from 24 to 38 months (HR = 0.6; 95% CI 0.5–0.8; p < 0.001). Several trials have established the equivalence of carboplatin and cisplatin when used in combination with paclitaxel in terms of progression-free and overall survival. However, the carboplatin and paclitaxel combination was significantly better tolerated,68,69 and it has been accepted as the standard of care in the first-line setting in patients fit enough for combination chemotherapy. A trial by the Japanese Gynaecologic Oncology Group (JGOG) showed that weekly, dose-dense paclitaxel in combination with carboplatin is superior to carboplatin and paclitaxel on a 3-weekly schedule, with an improvement in median progression-free survival from 17.2 to 28 months but reduced toxicity and this schedule should be considered for less fit patients.70 Carboplatin plus paclitaxel should also be offered to patients in whom primary surgery with optimal debulking is not possible with a re-assessment of the feasibility of debulking surgery after 3 cycles: the size of the residual tumour after the first surgical intervention (either primary or interval) remains the most important prognostic feature after surgery.71 Secondary cytoreduction after sub-optimal debulking has not been shown to be effective in improving survival.72 The results of the prospective EORTC 55971 trial comparing initial surgery followed by 6 cycles of carboplatin and paclitaxel with the same chemotherapy and surgery after 3 cycles show that optimal debulking mattered most while the timing of surgery did not. Postoperative complications were lower in the delayed surgery group.73 Final results of the CHORUS trial investigating the same approach are awaited. The GOG-182/ICON5 trial was a five-arm study that compared triple therapy carboplatin plus paclitaxel plus liposomal doxorubicin or gemcitabine, or sequential therapy with carboplatin plus topotecan or gemcitabine with carboplatin followed by carboplatin plus paclitaxel. The control arm was carboplatin plus paclitaxel.74 None of the experimental arms produced significantly improved survival. The Italian MITO-2 trial compared carboplatin plus paclitaxel with carboplatin plus

liposomal doxorubicin, with no survival or toxicity difference between the arms.75 GOG-218, a phase 3 study of carboplatin, paclitaxel, with or without the VEGF antibody bevacizumab in the adjuvant setting for stage III and IV patients showed that concurrent bevacizumab followed by 12 months bevacizumab maintenance was superior to carboplatin and paclitaxel alone with the median progression-free survival 14.1 and 10.3 months, respectively (HR = 0.72; 95% CI 0.63–0.82, p < 0.0001).76 There appeared to be no benefit for concurrent bevacizumab plus carboplatin and paclitaxel without subsequent maintenance bevacizumab. The results of a similar study (ICON7) confirm the benefit for maintenance bevacizumab following induction chemotherapy.77 Although neither study showed a significant overall survival benefit, maintenance bevacizumab is now licensed in stage 3 and 4 patients.

Intraperitoneal Chemotherapy In stage III disease, by definition, no cancer is found outside the peritoneal cavity. Delivering a high dose of active drug intraperitoneally directly to the sites of potential residual disease is attractive as it could achieve high drug concentrations while sparing systemic side effects. Intraperitoneal (IP) chemotherapy penetrates only to a depth of some millimetres, with cisplatin having a higher penetration than carboplatin in animal models.78 Only two randomised trials compared the intraperitoneal and intravenous routes using paclitaxel in the intravenous arm.79,80 Both trials enrolled patients with stage III disease who had been optimally debulked and randomised to either intravenous cisplatin and paclitaxel, or 2 cycles of high-dose carboplatin and paclitaxel, followed by intraperitoneal cisplatin (GOG114) or intravenous paclitaxel on day 1 and 8 and intraperitoneal cisplatin on day 2 of a 21 day cycle (GOG-172). Both trials showed a significantly improved progression-free and overall survival, at the cost of markedly increased toxicity and catheter complications, with only 42% completing all 6 cycles of intraperitoneal chemotherapy in GOG-172. Intraperitoneal chemotherapy has therefore not been widely adopted; its role remains the subject of much discussion. There is currently no role for intraperitoneal chemotherapy in stage IV, sub-optimally debulked or relapsed disease outside the context of a clinical trial.

Recurrent Disease The aim at relapse shifts towards symptom control in this incurable setting, and the choice of therapy should take this into account. Therapy should be started when the disease becomes symptomatic or the presence of bulky disease on computed tomography (CT). A rise in CA125 demonstrates disease recurrence but is not an indication for chemotherapy.81 Patients who require further chemotherapy within 6 months of carboplatin and paclitaxel are deemed platinum refractory and can expect response rates of at most 20% with subsequent, non-platinum containing therapy, e.g. weekly paclitaxel,

Medical Oncology in Gynaecology gemcitabine, topotecan or etoposide. Of these, weekly paclitaxel is probably the most active and best tolerated. Response rates increase with increasing time from the last chemotherapy; for patients with a disease-free interval >6 months, re-challenge with carboplatin plus another active agent is considered reasonable.82 The CALYPSO trial comparing carboplatin plus pegylated liposomal doxorubicin (PLD, Caelyx®) to carboplatin plus paclitaxel in women who had relapsed more than 6 months after first- or second-line chemotherapy with carboplatin and paclitaxel reported an improvement in median progression-free survival from 9.4 months to 11.3 months in the carboplatin plus doxorubicin arm, with more gastrointestinal toxicity in the carboplatin plus PLD arm, but less myelo- and peripheral neurotoxicity.83 It failed to show a significant overall survival benefit.84 Several trials have shown that carboplatin plus another active agent is superior to single agent carboplatin at platinum sensitive relapse (>6 months), and single agent carboplatin should be avoided.84,85 The OCEANS trial compared carboplatin and gemcitabine with the same chemotherapy and bevacizumab, the latter until progression. There was a clear progression-free survival benefit for the bevacizumab containing arm (HR =0.48; 95% CI, 0.39– 0.61; p < 0.0001) and a progression-free survival gain of 4.0 months, but no overall survival advantage to date.86 A similar benefit was found in the AURELIA study of single agent chemotherapy in platinum resistant disease compared with chemotherapy and bevacizumab until progression, with a median progression free survival gain of 3.3 months.87 In neither trial did patients receive bevacizumab in earlier lines of therapy, and it is not yet clear when the best time to use bevacizumab is. Small studies have confirmed activity of bevacizumab in end-stage ovarian carcinoma, both by symptomatic improvement of the malignant ascites,88 but also by demonstrating responses in measurable disease in 15–20% of patients.89,90

RARE G YNAEC O LO G IC AL MALIG NANC IES

Germ Cell Tumours Germ cell tumours are rare but are exquisitely chemosensitive. Fertility-sparing surgery is the standard approach, all patients except those with stage IA dysgerminoma and stage I, grade 1 immature teratoma should be offered postoperative BEP (bleomycin, etoposide and cisplatin) chemotherapy.91 In view of the known pulmonary toxicity of bleomycin, regimens without bleomycin have been trialled with no apparent loss of efficacy.92 Even for advanced stage dysgerminomas, the intent is curative with cure rates approaching 100%.93 The outcomes are slightly less good with non-dysgerminomas, and while the cure rate for early stage disease approaches 100%, for advanced stage is only around 75%.94 There is no standard therapy for relapsed disease and entry into a clinical trial should be offered if appropriate. Those with platinum-sensitive disease may be re-challenged with BEP, or if avoidance of bleomycin is desirable, VIP (etoposide, ifosfamide and cisplatin) although many regimens are recognised.95 In

platinum-resistant disease, therapy with VAC (vincristine, dactinomycin and cyclophosphamide) can be considered,96 as can high-dose therapy with stem cell rescue.94

Ovarian Stromal Tumours Ovarian stromal tumours are rare, but their prognosis is less good than for germ cell tumours, with 10-year survival between 20% and 30% for stage III and IV disease.97 Consequently, patients with stage 2–4 disease are often offered adjuvant chemotherapy, the accepted standard in the absence of randomised data being BEP.95 In addition, patients with stage I disease associated with high-risk feature should also be considered for BEP.98 It is not clear if bleomycin adds to the efficacy, and the superiority of BEP over EP has not been demonstrated. Interest in carboplatin and paclitaxel is rising as this combination also shows good activity without the toxicity of BEP.99 There is no standard therapy for relapsed disease, and entry into a clinical trial should be offered if appropriate. Patients with recurrent disease can be considered for VAC (vincristine, dactinomycin and cyclophosphamide) or paclitaxel as single agent or in combination with carboplatin or ifosfamide. Hormonal agents and bevacizumab have a role in relapsed granulosa cell tumours.95

19

Gestational Trophoblastic Tumours Gestational trophoblastic tumours are rare malignancies with an excellent outlook in specialist centres. They occur most commonly following a molar pregnancy (hydatidiform mole), although they can occur after normal pregnancy. Provided that β HCG levels fall to normal after evacuation of the hydatidiform mole, patients require careful follow-up only. Irrespective of the antecedent pregnancy, indications for chemotherapy are persistent or rising levels of β HCG post-partum or histological evidence of choriocarcinoma; this should be instigated as a matter of urgency. Low-risk disease (stage I and metastatic disease with a prognostic score100 less than 7) is usually treated with fertility-sparing intent. Single agent chemotherapy with methotrexate or actinomycin in methotrexate-resistant disease, is most commonly used with cure rates approaching 100%. For highrisk disease, dose intense chemotherapy with EMA-CO (alternating weekly etoposide, methotrexate, dactinomycin and vincristine, cyclophosphamide) is commonly used with substitution of vincristine and cyclophosphamide by further etoposide and cisplatin in relapsed disease.101

FUTURE DIREC TIO NS The incidence of ovarian carcinoma is increased in carriers of BRCA1 and BRCA2 mutations, and some sporadic ovarian carcinoma carry epigenetic silencing of the BRCA1 gene. In the absence of BRCA function, these cancers rely on the base excision repair pathway for repair of DNA damage, and drugs that inhibit the enzyme polyadenosine diphosphate-ribose 349

Section E | Aspects of Multidisciplinary Care in Gynaecology

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polymerase (PARP) in this pathway are therefore an important research target.102 Studies of the PARP inhibitor olaparib in BRCA mutation carriers have shown promising activity with response rates of around 40%,103 and studies are underway to test olaparib and other PARP inhibitors in patients not known to be BRCA mutation positive. Despite common expression of oestrogen receptors on ovarian cancer cells, neither tamoxifen104 nor aromatase inhibitors105 have produced the kind of clinical benefit seen with these agent in breast cancer, although their excellent tolerability makes them good targets to try prolonging the platinum-free interval in recurrent ovarian cancer. In addition to bevacizumab, other agents targeting the VEGF pathway, e.g. VEGF trap, VEGF tyrosine kinase inhibitor, are being evaluated but have not yet been introduced into clinical practice despite some promising early phase activity. Drugs targeting the human epidermal growth factor receptor family (predominantly EGFR and HER2) have largely been disappointing in the phase 2 setting. Drugs targeting the folate receptor, overexpressed in 90% of ovarian cancers, as well as a whole host of other targeted agents are being trialled in ovarian cancer and no conclusive results are available yet.106

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higpen JT, Blessing JA, DiSaia PJ, Fowler WC, Hatch KD. A randomized comparison of a rapid versus prolonged (24 hr) infusion of cisplatin in therapy of squamous cell carcinoma of the uterine cervix: a gynecologic oncology group study. Gynecol Oncol. 1989;32:198–202. Vermorken J. he role of chemotherapy in squamous cell carcinoma of the uterine cervix: a review. Int J Gynecol Cancer. 1993;3:129–142. Moore D, Blessing JA, McQuellon RP, et al. Phase III study of cisplatin with or without paclitaxel in stage IVB, recurrent, or persistent squamous cell carcinoma of the cervix: a gynecologic oncology group study. J Clin Oncol. 2004;22:3113. Long HJ 3rd, Bundy BN, Grendys EC Jr, et al. Randomized phase III trial of cisplatin with or without topotecan in carcinoma of the uterine cervix: a gynecologic oncology group Study. J Clin Oncol. 2005;23:4626–33. Monk BJ, Sill M, McMeekin DS, et al. A randomized phase III trial of four cisplatin (CIS) containing doublet combinations in stage IVB, recurrent or persistent cervical carcinoma: a gynecologic oncology group (GOG) study. J Clin Oncol. 2008;26:LBA5504. Greer BE, Koh WJ, Abu-Rustum NR, et al. Cervical cancer: Clinical practice guidelines in oncology. JNCCN. 2010;8(12):1388–1416. Samant R, Lau BEC, Le T, Tam T. Primary vaginal cancer treated with concurrent chemoradiation using Cis-platinum. Int J Radiat Oncol Biol Phys. 2007;69:746–50. Wahlen SA, Slater JD, Wagner RJ, et al. Concurrent radiation therapy and chemotherapy in the treatment of primary squamous cell carcinoma of the vulva. Cancer. 1995;75:2289–94. Montana GS, homas GM, Moore DH, et al. Preoperative chemoradiation for carcinoma of the vulva with N2/N3 nodes: a gynecologic oncology group study. Int J Radiat Oncol Biol Phys. 2000;48:1007–13. van Doorn HC, Ansink A, Verhaar-Langereis M, Stalpers L. Neoadjuvant chemoradiation for advanced primary vulvar cancer. Coch Datab Syst Rev. 2006;3:CD003752. Salom EM, Penalver M. Recurrent vulvar cancer. Curr Treat Opt Oncol. 2002;3:143–53. Hodi FS, O'Day SJ, McDermott DF, et al. Improved survival with ipilimumab in patients with metastatic melanoma. N Eng J Med. 2010;363:711–23. Guo J, Si L, Kong Y, et al. A phase II study of imatinib for advanced melanoma patients with KIT aberrations. J Clin Oncol. 2010;28:8527. Kim GE. Synchronous coexpression of epidermal growth factor receptor and cyclooxygenase-2 in carcinomas of the uterine cervix: A potential predictor of poor survival. Clin Cancer Res. 2004;10:1366–74. Monk BJ, Sill MW, Burger RA, Gray HJ, Buekers TE, Roman LD Phase II trial of bevacizumab in the treatment of persistent or recurrent squamous cell carcinoma of the cervix: a gynecologic oncology group study. J Clin Oncol. 2009;27:1069–74. Mackay HJ, Tinker A, Winquist E, et al. A phase II study of sunitinib in patients with locally advanced or metastatic cervical carcinoma: NCIC CTG Trial IND.184. Gynecol Oncol. 2004;116:163–7. Plataniotis G, Castiglione M. Endometrial cancer: ESMO Clinical Practice Guidelines for diagnosis, treatment and follow-up. Ann Oncol. 2010;21:v41–5. Greven KM, Curran WJ Jr, Whittington R, et al. Analysis of failure patterns in stage III endometrial carcinoma and therapeutic implications. Int J Radiat Oncol Biol Phys. 1989;17:35–9.

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Aspe c ts o f Ana e sthe sia a nd C ritic a l C a re fo r G yna e c o lo g ic a l Surg e ry

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Varunee Wirasinghe, Gabriel Browne

Intro duc tio n The anaesthetic and critical care of patients undergoing gynaecological surgery may present particular challenges. They represent a diverse group often with complex co-existing medical illnesses. Although primarily an adult cohort, germ cell tumours may require surgical intervention in young children. These are best managed in specialist children’s units. Procedures range from day cases to prolonged open pelvic surgery, and raise significant anaesthetic and critical care issues.

Pre - O pe ra tive Ana e sthe tic C o nside ra tio ns Information from pre-operative assessment aids anticipation of potential peri-operative problems, helps predict any requirement for postoperative critical care management and permits optimisation of patient care. Patient assessment must evaluate: Pre-existing co-morbidity and limitations on physiological reserve. Ongoing disease process and respiratory/cardiovascular/ gastrointestinal compromise as a result of, for example, a pelvic mass, neoplastic metastases or paraneoplastic syndromes. Impact of other treatment modalities, such as radiotherapy or chemotherapy. Cardiac, gastrointestinal, haematological and hepatic toxicity have been associated with various chemotherapeutic agents, in particular, platinum-based agents and anthracyclines. Investigations frequently required include blood biochemistry, blood counts and coagulation. Electrocardiogram (ECG) and chest radiographs may be requested where indicated during assessment. Further investigation may take the form of echocardiography, thallium scanning, lung function and cardiovascular physiology exercise testing (CPEX).1 Some or all of the results are used to guide optimal perioperative care, indicate risk of morbidity/mortality and offer useful information for risk-benefit assessment and planning. Special aspects of pre-operative assessment in this patient group concern (i) cardiovascular disease (ii) respiratory disease (iii) endocrine disease and (iv) obesity.

C ARDIO VASC ULAR DISEASE Cardiovascular disease is the commonest significant risk factor for anaesthesia and surgery. Several risk indices have been developed attempting to correlate clinical characteristics with peri-operative cardiac mortality and morbidity. The Lee index, a modification of the original Goldman index (1977), is considered by many clinicians to be the best currently available cardiac risk prediction index in non-cardiac surgery. The Lee index contains five independent clinical determinants of major peri-operative cardiac events in patients having high-risk types of surgery: a history of ischaemic heart disease, a history of cerebrovascular disease, heart failure, insulin-dependent diabetes mellitus and impaired renal function. All factors contribute equally to the index (a point each), and the incidence of major cardiac complications is estimated at 0.4%, 0.9%, 7% and 11% in patients with an index of 0, 1, 2 and 3 points, respectively.2 Ischaemic heart disease, valvular heart disease, arrhythmias and hypertension may be established or incidental findings. A peri-operative plan of management, further investigation if necessary and a plan for medication in the lead up to surgery, need to be carefully considered. In general, medications are taken as normal on the day of surgery, but for angiotensin-converting enzyme inhibitors only after anaesthetic consultation. Anticoagulant therapy demands risk-benefit analysis and is only discontinued when haemostasis is an anticipated problem.

RESPIRATO RY DISEASE Patients with chronic pulmonary airway disease should be optimised pre-operatively. This may include a course of antibiotics, bronchodilators and physiotherapy. Asthmatic patients can be at risk during anaesthesia due to the increased irritability of the bronchial smooth muscle and it is important to ascertain precipitating factors, recent hospital admissions, the necessity for previous steroid control, current exercise tolerance and peak expiratory flow rate. Pre- and postoperative nebulised bronchodilators may be helpful. Smoking may complicate the effects of asthma and patients should be encouraged to stop smoking for at least 48 hours before surgery.

ENDO C RINE DISEASE Diabetes and thyroid disease are the most common endocrine disorders with implications for anaesthesia. Diabetic patients

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on oral hypoglycaemic agents should stop their medication at the onset of pre-operative fasting, the last dose usually being 12–24 hours pre-operatively. They may then recommence medication with a normal diet after more minor operations. Insulin-dependent diabetics and those having major surgery must stop medication when normal oral intake ceases and the titration of intravenous short-acting insulin by a ‘sliding scale’ commenced to regulate blood sugar levels. Glycaemic control is an aspect of peri-operative management specifically addressed by the World Health Organisation (WHO) Surgical Safety Checklist. Patients with established thyroid disease should have recent normal thyroid function tests and be clinically euthyroid prior to proceeding with elective surgery. A raised index of suspicion of undiagnosed thyroid disease must be maintained for those noted to be symptomatic, in particular, a new arrhythmia or change in weight.

O BESITY Obesity is an increasingly common problem in many parts of the world. Patients who are morbidly obese (body mass index >35 kg/m2) are high risk for anaesthesia as well as surgery. Problems include difficult airway management, poor venous access, an increased incidence of cardio-respiratory complications and an increased risk of regurgitation and aspiration. Sleep apnoea and postoperative hypoxaemia are common, and the patient may require a period of mechanical ventilation postoperatively and should be managed on the intensive care or high-dependency unit. Patients who have had gastric banding to manage obesity may have a reduced rate of gastric emptying and a potentially raised risk of regurgitation.

WHERE AND WHEN TO PRE- ASSESS? Pre-assessment is ideally undertaken in a pre-admission clinic offering phlebotomy and the facility to organise ECG or chest X-ray within a single session. Assessment is often by skilled, senior nurses employing a ‘traffic-light’ system for requesting investigations.3 Referral for anaesthetic assessment is made by a member of the surgical team or the pre-assessment clinic nurse where indicated. Pre-assessment should occur at a time pre-operatively that allows sufficient time to arrange for further investigation or medical management. Equally, the timing should not be so far ahead that changes in the patient’s condition may render the assessment obsolete.

Gynaecological procedures such as dilatation and curettage, colposcopy, hysteroscopy and laparoscopy lend themselves well to the day surgical setting. The patient cohort, generally young ASA (American Society of Anaesthesiologists) grade 1 or 2, renders this safe and efficient. Conditions such as obesity and diabetes offer contention over management and institutions running day case units should have guidelines outlining policy. These may be subject to exception with consultant surgical and anaesthetic input. Postoperative nausea and vomiting (PONV) represents a particular problem in this group of patients. Risk assessment is by an Apfel scoring system, or similar, awarding points for female gender, a history of PONV or motion sickness and non-smokers. Anaesthetic techniques to minimise PONV include the use of total intravenous anaesthesia (TIVA), avoiding nitrous oxide and gastric insufflation, adequate hydration and avoidance of prolonged starvation, minimising opioids and using prophylactic anti-emetics. Pharmacological agents used in managing PONV interact with multiple receptors. Ondansetron, a 5HT3 antagonist, and cyclizine, with antihistamine and antimuscarinic effects, are often used in conjunction for this purpose.4

La pa ro sc o pic Pro c e dure s Respiratory and cardiovascular compromise as a consequence of the pneumoperitoneum raises significant anaesthetic concerns. Bradycardia after peritoneal insufflation is common, rarely progressing to asystole, so rapid deflation may be required if there is inadequate response to treatment with vagolytic agents such as glycopyrrolate or atropine. The increased intra-abdominal pressure may reduce systemic blood pressure by reducing venous return. Often however, no change in systolic blood pressure is observed as it is maintained by a compensatory increase in systemic vascular resistance. The pneumoperitoneum acts as a ‘splint’ to the diaphragm, reducing lung compliance and functional residual capacity. Hypoventilation and high airway pressures must be anticipated and managed. Surgical emphysema as a result of an inadequately advanced Veress needle may be an additional cause of rising blood carbon dioxide level, requiring management with a period of prolonged ventilation under anaesthesia.5 Robotic-assisted laparoscopic surgical intervention is a more recent development. In offering the option of remote precise control of surgical instruments and reduced hospital stay, the process also presents new anaesthetic challenges.

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Day case surgery continues to expand to include more complex patients and surgical procedures. The aim to achieve a painfree, ambulant patient requires careful patient and procedure selection.

These include abdominal hysterectomy, radical trachelectomy, lymph node dissection and major vulval surgery. Urological or plastic reconstructive surgical input may be required. In addition, major operations may be undertaken in stages or involve redo processes with incumbent surgical, anaesthetic and critical care implications.

Aspects of Anaesthesia and Critical Care for Gynaecological Surgery General anaesthesia with tracheal intubation and ventilation is usually necessary to facilitate prolonged and possibly technically difficult surgery. Regional anaesthesia can provide operative anaesthesia and intra/postoperative analgesia to minimise the need for intraoperative opioid, attenuate the stress response to surgery and offer other advantages, discussed later. A combination with other analgesic modalities such as intravenous paracetamol, non-steroidal anti-inflammatory drugs (NSAIDs), opioids, clonidine and ketamine is used with success.

Ve no us Thro m b o e m b o lism Venous thromboembolism (VTE) is an important cause of morbidity and mortality in the hospital population. The National Institute for Health and Clinical Excellence (NICE) has specified obesity, age over 60 years, use of hormonereplacement therapy or oestrogen-containing contraceptives, cancer, general anaesthesia and prolonged immobility perioperatively as significant risk factors for VTE.6 Their clinical guideline offers best practice advice on assessing and reducing the risk of VTE in patients admitted to hospital. It identifies mechanical and pharmacological modalities of prophylaxis. Pharmacological options, in those who have a low risk of major bleeding, include low molecular weight heparin, fondaparinux (Factor Xa inhibitor) or unfractionated heparin. Mechanical options include anti-embolism stockings, foot impulse devices and intermittent pneumatic compression devices. Patients on oestrogen-containing oral contraceptives or hormone-replacement therapy may be advised to consider stopping these 4 weeks before elective surgery. Regional anaesthesia carries a lower risk of VTE than general anaesthesia. If regional anaesthesia is used, planned timing of pharmacological VTE prophylaxis to minimise the risk of epidural haematoma is necessary.

Po sitio ning Most procedures are undertaken in the Lloyd-Davies or lithotomy positions. The lumbar spine, hip joints and common peroneal nerves are at risk and need special attention on positioning, with use of padding to avoid nerve injury. Arms need to be secured carefully to avoid displacement during operation. Because of its superficial course, the ulnar nerve is at special risk of injury. It too should be carefully padded. Head down tilt increases pressure of intra-abdominal contents on the thorax. Ventilation and venous drainage from the head is compromised in this position. At the end of surgery, reversal of head-down tilt and lowering legs can suddenly reduce venous return. This must be anticipated with careful patient monitoring, and intravenous fluid and vasoconstrictors readily available. Placement of cables and breathing circuits must be secured to prevent these being trapped by surgical clamps fixed to the

operating table. These also need to be placed so as to avoid pressure damage to the patient, with special attention to infusion lines from the fluid warmer where there is the added risk of causing skin burns.

Ha e m o rrha g e a nd Ha e m o sta sis Anaesthetic considerations involve pre-operative assessment of risk by surgical procedure and patient factors to include comorbidity and anticoagulant medication. Anticipation of increased blood loss prompts preparation with cross-matched blood, adequate large-bore intravenous access and invasive monitoring to guide fluid balance as well as provide access for regular blood sampling of blood gases, blood counts and coagulation tests.7 Replacement of packed red cells and fresh frozen plasma in equal ratios is recommended for acute major blood loss. Platelets, cryoprecipitate, recombinant clotting factors (Octaplex, Beriplex), vitamin K, calcium and Tranexamic acid must also be considered in the context of acute major blood loss. Temperature homeostasis is also important in avoiding coagulopathy in this circumstance. Occasionally, anaesthesia and resuscitation may need to be undertaken whilst transferring the patient to a facility for interventional radiology and embolisation. Meticulous planning and preparation for safe patient transfer to and from this remote location must take into account monitoring, drugs/ infusions, emergency resuscitation equipment and skilled assistance.

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Te m pe ra ture Ho m e o sta sis Patients who develop peri-operative hypothermia can experience a number of complications including increased peri-operative blood loss, longer post-anaesthetic recovery, morbid cardiac events, altered drug metabolism, surgical wound infection and delayed healing. Any of these may lead to a longer stay in hospital, patient distress and discomfort, and even death. Forced air warming devices, warmed intravenous and irrigation fluids and regular temperature monitoring are advocated by NICE in an attempt to maintain peri-operative temperature above 36°C.8

Re g io na l Ana e sthe sia The role of local anaesthetics and regional anaesthesia in gynaecological surgery is significantly increasing. Improved techniques and new local anaesthetic agents such as ropivacaine and levo-bupivacaine, with improved cardiac and neurological safety profiles, have contributed to this. Ultrasound guidance offering real-time visualisation of fascial planes, nerves and surrounding anatomy have afforded more accurate deposition of local anaesthetic. Research on outcomes and long-term sequelae will determine whether the effectiveness and safety of regional anaesthesia has

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been improved by ultrasonography.9 Regional anaesthesia techniques include: 1. Local infiltration 2. Epidural anaesthesia 3. Spinal anaesthesia 4. Combined spinal epidural 5. Caudal anaesthesia 6. Transversus abdominis plane block

LO C AL INFILTRATIO N

Abdominal Procedures Laparoscopy and laparoscopic sterilisation are widely carried out under local anaesthesia. Technique: The puncture sites are infiltrated with lignocaine 1% to include the parietal peritoneum. This should be injected in a radial fashion from the umbilicus to include the needle track and a fan-shaped area on either side. The Fallopian tubes may be anaesthetised by dropping 5 mL of 1% lignocaine through a long fine spray cannula, or pelvic instillation of ropivacaine 200 mg in 40 mL saline.10

Vaginal and Vulval Surgery For minor surgery on the vulva or vagina, local infiltration with 1% lignocaine or 0.5% bupivacaine is effective. For endocervical curettage, paracervical block is required. Eight to ten millilitres of local anaesthetic are injected into each lateral fornix; injection must be preceded by aspiration. Either lignocaine 1% or bupivacaine 0.25–0.5% can be used. By combining lignocaine with 1:200,000 of adrenaline the duration of action can be increased from one to up to 2 hours and the maximum safe dose increased from 3 to 7 mg/kg. The onset of action is rapid. There is no block of the vagina or perineum. The onset of action of bupivacaine is less rapid than lignocaine but the duration of action of 6–8 hours is considerably longer. The addition of adrenaline does not significantly prolong the duration of action of bupivacaine.

Complications Local anaesthetic-induced convulsions can occur requiring treatment with a benzodiazepine or thiopentone and which, if severe, can lead to cardiac arrest.

EPIDURAL ANAESTHESIA The contraindications to epidural and spinal anaesthesia are summarised below: Sepsis/localised infection around puncture site Generalised infection (septicaemia, bacteraemia) Abnormal coagulation Hypotension/shock/hypovolaemia Raised intracranial pressure Cardiovascular disease, low-output conditions Diseases of the spinal column (metastases, tumour) Local anaesthetic drug sensitivity 358

Patient refusal Technical difficulties, i.e. kyphoscoliosis, obesity Medico-legal implications Neurological disease

Contraindications to Epidural/Spinal Anaesthesia If an epidural is planned as part of the anaesthetic technique, it is advisable to ensure that subcutaneous heparin, if used, is given latest 12 hours beforehand. Most epidurals are now inserted, with the patient conscious and cooperative before general anaesthesia is induced. Local analgesia is used and occasionally small amounts of benzodiazepine sedation. The sitting position is often used to ensure a successful epidural siting. Full aseptic precautions should be observed and current practice is to insert a catheter through the epidural needle in order to prolong the block during surgery and to use the epidural for postoperative pain relief. Intraoperative boluses of local anaesthetic can be given, usually 5–10 mL of 0.25–0.5% bupivacaine which can be followed by an infusion of 0.125% bupivacaine for postoperative pain relief. Commonly the epidural local anaesthetic will include an infusion of the opioid fentanyl. Chirocaine or ropivacaine may be employed as the local anaesthetic.

Complications of Epidural Anaesthesia Respiratory depression Hypotension Dural tap and post-dural puncture headache Epidural haematoma Failure Nausea/vomiting Urinary retention Reaction to local anaesthetic Infection Total spinal

SPINAL ANAESTHESIA Spinal anaesthesia is produced by the injection of a local anaesthetic solution into the cerebrospinal fluid (CSF) causing temporary axonal block. The injection is usually performed at L3-4 below the termination of the spinal cord at L1-2 to avoid damage to the cord. The technique is performed with the patient in the lateral or sitting position on a tipping trolley. Following venous access, monitoring of blood pressure, ECG and oxygen saturation should be established. Facilities for full resuscitation must be available.

Technique Under strict aseptic precautions, the back is cleaned with antiseptic solution and the appropriate space located by palpation. The needle is inserted at right angles to both the horizontal and vertical planes. The needle is advanced through the skin and subcutaneous tissue until resistance is felt as it enters the supraspinous and inter-spinous ligament and then the ligamen-

Aspects of Anaesthesia and Critical Care for Gynaecological Surgery tum flavum. Further advance causes the needle to penetrate the dura. The stylet is removed and CSF will leak from the hub of the needle confirming correct placement. Subsequently, 0.5% heavy bupivacaine 2–4 mL is slowly injected. With spinal anaesthesia the smaller the bore of the needle, the less likely the patient is to develop post-dural puncture headache (PDPH),11 a distressing and often prolonged complication. However the use of a small bore needle (25–29 G) may necessitate the use of an introducer to facilitate passage through the skin and ligaments. With the advent of small gauge spinal needles, and the increasingly common practice of performing Caesarean section under a spinal anaesthetic, more operations are now being performed under spinal anaesthesia in situations where general anaesthesia is not available. It is essential, however, to have facilities for assisted ventilation and resuscitation should the need arise.

formed by the superior part of the sacro-coccygeal ligament. A 19 or 21 gauge needle is inserted, immediately caudad to the thumb at an angle of about 45°. Resistance is felt as the needle engages in the ligament and is followed by a loss of resistance as it enters the sacral extradural space. The angle is now changed to become parallel with the long axis of the sacrum and the needle advanced. If resistance is felt the needle has either passed beneath periosteum or is situated subcutaneously. Should this occur the needle should be removed and the procedure recommenced. After aspiration to ensure the absence of blood or CSF the local anaesthetic is then injected. Bupivacaine 0.25% or 0.5% in a dose of 20 mL is usually adequate for perineal procedures.

Complications

The TAP block aims to deliver local anaesthetic to the branches of the anterior rami of the spinal nerves supplying the anterior abdominal wall (T7-L1) as they traverse the plane between the transversus abdominis and internal oblique muscle layers. The technique, initially described as a blind procedure within the lumbar triangle of Petit, has been the subject of recent renewed interest under ultrasound guidance. The block offers the possibility of extensive sensory nerve block with minimal risks relative to the alternative central neuraxial blocks. Its uptake has been primarily as a single-shot technique, but may afford prolonged block if a catheter is tunneled into the space. Reports of liver trauma, intraperitoneal injection, bowel haematoma and transient femoral nerve palsy exist, but the block remains one of the safest techniques in experienced hands.12,13

Complications of spinal anaesthesia include total spinal anaesthesia resulting in apnoea and loss of consciousness, which may lead to cardiac arrest. Immediate treatment with tracheal intubation and ventilation with 100% oxygen should be instituted; cardiovascular support may be necessary. Other complications include hypotension, which should be treated with fluids and vasopressors (generally ephedrine in 3–6 mg increments), and rarely neurological damage. This includes haematoma formation, cord ischaemia, infection/aseptic meningitis and arachnoiditis. Anaphylactic reaction to local anaesthetic is extremely rare.

C O MBINED SPINAL EPIDURAL The combined spinal and epidural (CSE) is an increasingly popular technique, combining the advantages of the two techniques. The Tuohy needle is essentially used as an introducer for the spinal needle prior to its use for catheterisation of the epidural space. The speed of spinal anaesthesia is then available in conjunction with duration afforded by the epidural component. The CSE has a more widespread role in obstetric anaesthesia than for gynaecological surgery.

C AUDAL ANAESTHESIA Caudal anaesthesia is technically easier to perform than an epidural but because of inconstant anatomy the success rate is not as high. It is a useful technique to augment anaesthesia for vaginal or perineal surgery. The extra-dural space runs from the foramen magnum to the base of the sacrum where it is sealed off by the sacrococcygeal ligament. Generally, the dural sac ends at the inferior border of the second sacral vertebral and the spinal cord at the inferior border of the first lumbar vertebra. However, there is much variation.

Technique The block is performed with the patient in the lateral position. The sacral cornua are palpated, the thumb is drawn cephalad until bone is felt in the midline. This is the apex of the triangle

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TRANSVERSUS ABDO MINIS PLANE (TAP) BLO C K

Po sto pe ra tive Pa in Ma na g e m e nt A multimodal approach is used where possible. Paracetamol and non-steroidal anti-inflammatory drugs (NSAIDs), where not contraindicated, are available for use in intravenous, oral and rectal preparations. These, in combination with regional anaesthetic techniques, may be used to minimise opioid use and facilitate rapid recovery postoperatively. Morphine, oxycodone and oxynorm are the more commonly used opioids for postoperative analgesia. Morphine and fentanyl are used with great success in patient-controlled analgesia (PCA) pumps in order to optimise dosing whilst maintaining safety with a programmed maximum bolus and lockout time. Side-effects may be further minimised by using an opioid antagonist, such as methylnaltrexone to counter opioid-induced constipation acting peripherally within the gastrointestinal tract. Input from a Pain Team is invaluable to ensure adequate management of postoperative analgesia after major surgery. This is particularly so where catheter techniques have been employed and where PCA or patient-controlled epidural analgesia (PCEA) devices are in use. Patients with pre-existing chronic pain problems and patients with drug dependence or tolerance problems have

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Section E | Aspects of Multidisciplinary Care in Gynaecology much to gain from regular input and assessment by such specialist services.14

Enha nc e d Re c o ve ry

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The UK Department of Health currently promotes enhanced recovery programmes in an attempt to promote evidencebased, multidisciplinary optimal patient management perioperatively to improve outcomes and early discharge.15 Elements of the pathway have been addressed earlier within this chapter.

C ritic a l C a re The critical care unit is the hospital facility offering intensive staffing and organ support resources continuously. Led by a consultant intensivist with 24-hour resident medical staff and 1:1 or 1:2 nurse:patient ratio, critical care is able to offer maximal intensive therapy where indicated. Admission may be elective or as an emergency, and is occasionally arranged pre-operatively for so called ‘pre-operative physiological optimisation’. Elective postoperative CCU admissions are triggered by the patient’s history, pre-assessment findings and complexity of the surgical procedure. Severe cardiorespiratory disease, such as pulmonary hypertension, and neuromuscular disorders are examples of conditions predictably warranting postoperative intensive care for invasive monitoring and organ support. Highdependency nursing may be required in those with complex analgesia concerns, which may include the support of epidural infusions. Haemorrhage and sepsis are the commonest causes of emergency admissions to the critical care unit following gynaecological surgery. Other indications include complications of a large pulmonary embolism, cardiac arrest and rarer serious untoward anaesthetic or surgical incidents.

RESPIRATO RY SUPPO RT Respiratory failure after gynaecological surgery as a consequence of opiates, infection, pulmonary embolus, oedema, pneumothorax, lymphangitic spread of cancer, massive ascites or exacerbation of pre-existing lung disease may require more support than supplemental-inhaled oxygen available on the ward. Obesity and a history of obstructive sleep apnoea add to the risk of deterioration in respiratory function postoperatively. Critical care is able to support ventilation non-invasively or invasively whilst definitive management of the underlying precipitant is managed by inter-costal drains, bronchodilators, anticoagulants, antibiotics or steroids. Regular chest physiotherapy is a key component of optimal respiratory support. Usually the physiotherapist will have also assessed the patient pre-operatively and planned together the rehabilitation activity. Invasive ventilatory modes via endotracheal tubes range from simple pressure or volume-controlled modes through to the more 360

intensive high-frequency ventilatory modes utilising frequencies in the range of 3–10 Hz. Where significant disease impairs gas exchange to the extent that further escalation ventilatory mode is no longer possible, the use of nebulised prostacyclin/sildenafil or prone positioning to improve ventilation-perfusion mismatch may be considered prior to resorting to extra-corporeal membrane oxygenation (ECMO) via a bypass machine. The aim is to successfully wean off invasive support in the shortest feasible time in order to avoid the complications of ventilator-induced lung injury (VILI) and ventilator-associated pneumonia (VAP). Long-term mechanical ventilation, where inevitable, in the awake patient is administered via a tracheostomy. The decision for this is based on predicted prolonged respiratory wean, or where the patient is unable to protect their own airway when self-ventilating. Percutaneous bedside tracheostomy is a procedure often performed by the intensivist using a Seldinger dilatation technique.

C ARDIO VASC ULAR SUPPO RT Cardiovascular support is required in patients at risk of circulatory instability as a result of haemorrhage, sepsis, or return of circulation after cardiac arrest in the peri-operative period. A balance of fluid resuscitation and inotropic support is necessary to optimise tissue perfusion, whilst minimising damage to other organ systems from the initial insult and resuscitative measures. Pulmonary oedema, oedema or vasoconstriction at anastomoses, mesenteric hypoperfusion, cardiac and renal failure are all recognised complications of the management of shock. Monitoring clinical signs and symptoms and regular blood gases, together with a high index of suspicion, aids detection and early management of these sequelae. Management of haemorrhage by means of massive blood transfusion, early correction of coagulopathy and reversal of the cause of blood loss has been discussed earlier. Large bore peripheral access (14G, 16G cannulae) or central access (8Fr Swann sheath introducer) facilitate rapid infusion of intravenous fluid where acute blood loss is the primary problem. Invasive central venous pressure monitoring via central venous catheter, central venous saturation, oesophageal Doppler monitoring, and further invasive monitoring via the arterial waveform and thermodilution or dye-dilution (PiCCO, LidCO), are all commonly used to monitor cardiac output and to guide fluid resuscitation. Vasoactive drugs in the form of vasoconstrictors (norepinephrine, vasopressin) and inotropes (epinephrine, dobutamine) are selected and titrated to clinical parameters in conjunction with adequate management of hypovolaemia.

Vasopressor Therapy The initial inotropic agent employed in patients with clinical signs of shock and hypotension not responsive to empiric fluid challenge is noradrenaline in order to support organ perfusion pressure. Pulmonary artery catheterisation to guide fluid and inotropic support is now reserved for the more complex

Aspects of Anaesthesia and Critical Care for Gynaecological Surgery patients. The vast majority of critically ill patients are monitored with the less invasive oesophageal Doppler and/or PiCCO or LidCO devices, as previously discussed. Epinephrine should be considered for refractory hypotension although adverse dysrhythmic effects are common. Vasopressin is commonly employed when the above measures have failed and may allow the reduction of toxic higher doses of noradrenaline. In severe septic shock, adrenal output may be inhibited and corticosteroid administration may be helpful in some patients.16; However, its use is tempered with the knowledge of increased susceptibility to infection and also prolonged critical illness neuropathy/myopathy syndrome.

Inotropic Therapy Dobutamine is the first choice for patients with a low cardiac index (4.5 L/min/m2) has not been shown to improve outcome in the postoperative period. Bedside echocardiography by an experienced cardiologist can be a very useful and non-invasive examination to rule out cardiac tamponade, to look for vegetations on heart valves and to estimate left and right ventricular function.

C ARDIAC ARREST The management of cardiac arrest is governed by the European Resuscitation Council Guidelines for resuscitation and advanced life support. The protocol is reviewed regularly with the emphasis in recent years being on chest compressions with shock delivery in VF/VT as soon as possible.17 Education of all team members of the algorithm, and regular updating of skills and knowledge is necessary for successful resuscitation. Intubation and mechanical ventilation, inotropic support, together with neuroprotectivecontrolled hypothermia to 34°C for 24 hours post-VF arrest, are the initial measures on admission to the unit following return of spontaneous circulation. Sadly, a significant proportion of such patients will die despite all efforts.

RENAL SUPPO RT Acute renal failure requiring critical care support in gynaecological surgery is most often the result of tissue oxygen deprivation secondary to reduced intravascular volume, or reduction in perfusion pressure. Obstruction or ureteric damage at surgery must be excluded as a cause of renal failure. Once circulatory support has been optimised, infusion of a loop diuretic such as frusemide may be considered. Indications for renal replacement therapy in the form of continuous veno-venous haemofiltration include hyperkalaemia, severe uraemia, acidaemia and fluid overload.

G ASTRO INTESTINAL SUPPO RT Maintenance of adequate nutrition and early enteral feeding are important features of critical care support. Enteral feeding orally, nasogastrically, nasojejunally, via feeding jejunostomy or percutaneous gastrostomy is preferable to the parenteral route.18 There is evidence for a reduction in bacterial translocation and sepsis from a gastrointestinal source with use of the enteral route, and the infective complications of parenteral nutrition are avoided. Prolonged paralytic ileus is the commonest cause of CCU gynaecological surgical patients being unable to feed via the enteral route. Complications resulting in the formation of enterocutaneous fistulae may also prevent adequate enteral nutrition. Dietary supplements such as glutamine are used in a critical care setting as there is evidence to show a reduction in frequency of pneumonia, sepsis and bacteraemia in patients who received glutamine-supplemented enteral nutrition. Other vitamin and calorie supplements are also used in some units. Input from a dietitian is invaluable in this setting.19

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SEPSIS Sepsis is a clinical syndrome that complicates severe infection and is characterised by systemic inflammation and widespread tissue injury. It is mediated by various cytokines-released systemically as a response to infection. Patients on chemotherapeutic drugs, those with cancer, diabetes and invasive catheters or tubes (e.g. for ventilation) have impaired defense mechanisms and are at an increased risk of sepsis and multi-organ failure. The development of severe sepsis may be prevented by avoidance of invasive catheters, use of full aseptic techniques when siting them and removing them as soon as possible. Prophylactic antibiotics in the peri-operative phase may be beneficial. Sepsis syndrome is recognised clinically by the presence of two or more of the following: Temperature greater than 38°C or less than 36°C. Heart rate greater than 90 beats/min. Respiratory rate greater than 20 breaths/min or a PaCO2 in arterial gas less than 32 mmHg WBC count greater than 12,000 cells/μL or less than 4000 cells/μL. Septic shock is sepsis with hypotension (systolic BP